NURSING CARE OF CHILDREN WITH

COMMON NEONATAL DISORDERS

 Birth injuries
 Caput succedaneum
 Cephalhematoma

 Fractures

 Facial paralysis
 Erb’s/Brachial palsy
 Disorders related to physiological factors
§ Hyperbilirubinemia
§ Hypoglycemia

§ Hypocalcemia
§ Hypothermia

§ Hemolytic disease of the newborn

§ Respiratory distress syndrome

 Disorders related to infectious process
 Sepsis
 Necrotizing enterocolitis
 Disorders related to maternal conditions

 Infants of diabetic mothers

 Injuries to head

 Caput succedenum
 Cephalhematoma
 CAPUT SUCCEDANEUM

 A caput succedaneum is an edema of the scalp at the neonate’s

presenting part of the head

 It often appears over the vertex of the newborn’s head as a result of

pressure against the mother’s cervix during labor.

 The edema in caput succedaneum crosses the suture lines

Causes

 Mechanical trauma of the initial portion of scalp pushing through a

narrowed cervix

 Prolonged or difficult delivery

 Vacuum extraction
 Cephalhematoma

 It is a collection of blood between the periosteum of a skull bone and the

bone itself (the cranial bone and the periosteal membrane). It occurs in one or

both sides of the head

 The swelling with cephalhematoma is not present at birth rather it develops

within the first 24 to 48 hours after birth.  Disappear with in 2 to 3 weeks

 Has clear edges that end at the suture lines.Unilateral or bilateral and do not

cross suture lines

Causes

 Rupture of a periostal capillary due to the pressure of birth

 Instrumental delivery
 Nursing care management
 Assessment and observation of the common scalp
injuries and vigilance in observing for possible
associated complications such as infection or acute
blood loss and hypovolemia.
 Visible injuries resolves spontaneously, parents
need reassurance.
 Fractured clavicle

Bone most frequently fractured during delivery

 Associated with CPD

Signs

 limited ROM,

 crepitus,

 cries of pain when arm is moved,

 absent Moro reflex on Affected side

 Heals quickly, handle gently, immobilize arm, eliciting scarf sign is contraindicated.

 Any newborn that weighs more than 3800gm and is delivered vaginally should be

evaluated for a fractured clavicle.

 Fractured clavicle

Nursing Management

 Often no intervention is needed other than maintaining proper

alignment, careful dressing and undressing of infant.

 Support the child from upper and lower back other than from under

the arms should be practiced.

 Facial paralysis
 From pressure on facial nerve during delivery
 Affected side unresponsive when crying

 Resolves in hours/days
NURSING MANAGEMENT-
a) Gavage feedings may be given to prevent aspiration
b) Since the eye on the effected side cannot be closed
completely, it is covered with an eye shield to prevent
drying of the conjunctiva and cornea.
 Erb’s Palsy (Erb- Duchenne Paralysis)

 Associated with stretching or pulling head away from

shoulder during delivery

Signs

§ Flaccid arm, elbow extended, hand rotated inward,

Moro & grasp reflexes absent on affected side

 Requires immobilization & reposition for 2 to 3 hr.

 NURSING MANAGEMENT-

a) The goal is to prevent contractures in the paralyzed muscles. The arm

should be partially mobilized in a position of maximum relaxation so that

the non-paralyzed muscles cannot exert pull on the affected muscles.

b) By use of a splint or brace when upper arm is paralyzed, the arm is

abducted 90 degrees and rotated externally at the shoulder with the

elbow flexed so that the palm of the hand is turned towards the head.

 When immobilization is used, the fingers and the hand should be

observed for coldness and discoloration and the skin for the signs of

irritation.
 Hemolytic disease of the newborn

§ Rh +ve blood – D antigen

§ Rh -ve blood – lacks this D antigen

§When Rh +ve blood is infused into an Rh- ve woman through error

or when small quantities (usually more than 1 mL) of Rh- positive fetal

blood containing D antigen inherited from an Rh-positive father enter

the maternal circulation during pregnancy, with spontaneous or

induced abortion, or at delivery, antibody formation against D antigen

§ As the mixing of blood usually occurs at the time of delivery so by

the time antibodies are formed the baby is already delivered.

 Hemolytic disease of the newborn

 Prevention of hemolytic disease

§ Prevention: Rhogham/Anti- RhD in un-sensitized mothers

§ Treatment of a mother with Anti-RhD antibodies prior to and

immediately after trauma and delivery destroys Rh antigen in

the mother's system from the fetus

Diagnosis:

§ Indirect coombs test in mothers-antigen

§ direct coombs test in infants with Rh-ve mothers-antibodies

Treatment:

IVIG is given in infants, exchange transfusion and phototherapy.

Nursing management:

1. Early recognition of Jaundice

2. If an exchange transfusion is required then the nurse prepares the infant and

family and assists the physician.

3.The nurse documents the blood volume exchange.

4. Signs of blood transfusion reaction are need to be monitored.

5.Throughout the procedure infant’s thermoregulation need to be monitored.

6. After the procedure the nurse monitors the umblical cord for any kind of

bleeding.
 Neonate Respiratory distress syndrome/
Hyaline membrane disease
 RDS occurs primarily in premature infants & rarely at term

 its incidence is inversely related to gestational age and birth weight.

§ It occurs in 60–80% of infants less than 28 wk of gestational age,

§ In 15–30% of those between 32 and 36 wk,

 In about 5% beyond 37 wk,

  The condition occurs due to lack of pulmonary surfactant because of

immaturity of the lungs.

 Surfactant helps in reducing the surface tension of alveoli.

§ When surfactant active material is deficient in the alveoli, there is

alveolar collapse during expiration

§ The pulmonary immaturity of the fetal lungs can be assessed by

determination of lecithin/sphingomyelin ratio in the amniotic fluid

§ L/S ratio is 2:1 or more suggestive of adequate lung maturity, while a ratio of

less than 1.5 is often associated with HMD

Clinical features

§ This is characterized by a triad of tachypnea, expiratory grunt and inspiratory

retractions in a preterm.

 These symptoms may begin at birth or within 6 hours of birth.

 There is a gradual worsening of retractions, grunting and cyanosis.

Management

• Premature labor should be arrested by appropriate tocolytic therapy to gain pulmonary maturity.

 The induction of labor should be delayed as far as the lung maturity is confirmed by l/S ratio.

• When premature labor below 34 weeks of gestation is unavoidable, the mother should be given

betamethasone 12mg IM every 24hrs for two days or dexamethasone 6mg IM four doses at an

interval of 12hrs. (31-34wk)

 The infant should be nursed in a thermo neutral environment and administered oxygen through

head box. 

 An IV line should be established to maintain fluid and electrolyte balance, for correction of

acidosis and administration of drugs.

• Intratracheal administration of surfactant should be done

• SPo2 should be monitored

• If infant cant monitor Spo2 above 90 despite of giving oxygen via hood the infant should be put

on CPAP
• If CPAP is also ineffective then the infant should be

put on IPPV (ventilate)

• Antibiotics are given in case of superadded

infections

• The management of HMD requires supportive care

by trained nurses and the availability of high

technology to monitor and manage the hypoxia due

to ineffective ventilation.
 Nursing management
 Effective ventilation and oxygen therapy
  Equipment should be ready and in working condition
  Oxygen must be warm and humidified
  The condition of the infant can change in a fraction of a second so it is vital for the
nurse to monitor neonate’s color, level of activity and to note blood gas
measurements.
  When o2 is given, tracheal and nasopharyngeal suctioning and chest physical therapy
is required.
 Optimal environmental temperature:
• The nurse has a important role in providing regulation of surrounding temperature.
•  Adequate nutrition: proper gavage feedings at proper intervals is necessary nursing
action.
•  Minimal handling of critically ill infants.
•  Use of aseptic techniques.
•  Infants should be positioned with head elevated to decrease pressure on
diaphragm.
 Necrotising Enterocolitis (NEC)

• This is characterized by necrosis of intestinal wall , is a serious life

threatening condition that is being diagnosed with increasing frequency
in premature infants.

Factors that place the infant at risk of this disease

• Perinatal asphyxia

• Low apgar score

• IRDS

• Sepsis

• Enteral feedings

• Congenital cardiac disease

• Relative ischemia of the intestinal tract that is due to hypotension

 Pathophysiology

• Depletion of the normal blood flow Ischemia with a reduction in the protective mucosa,

destroy the mucosal layer

• Bacteria in the infants feeding form gas in the intestines and it becomes dilated, become

necrotic. Necrosis may involve the full thickness of the intestinal wall leading to ultimate

perforation

Clinical manifestations

• Abdominal distention

• Decreased bowel sounds

• Poor feeding

• Increased gastric residuals

• Blood streak bile vomiting

• Bloody or mucoid stools

 Nursing management

• As soon as the diagnose of NEC is made the oral feedings are

discontinued and peripheral IV fluids are given to the infant.

• Palpation of abdomen, abdominal girth are checked daily

• Bowel sound monitoring

• TPN is to be started

• I/v antibiotics are started to against gram negative enteric

organisms

• Affected infants are to be placed in isolation

 These infants are not diapered because of the increased risk of
intra-abdominal pressure.

 These infants are nursed on their back as much as possible to reduce

the external pressure on the abdomen

 Postoperatively , as the suture line is close to stoma so measures

should be taken to avoid any infection to suture line.

 Psychological support should be given to parents.

 Neonatal Sepsis
§ Systemic bacterial infections of newborn infants are termed as
neonatal sepsis
§ They are the most common cause of neonatal deaths in India

§ This is a generic term which incorporates neonatal septicemia,

pneumonia, meningitis and urinary tract infections
Neonatal sepsis can be divided into two types
Early onset: this happens in first 72 hours of life
• This is mainly due to organisms present in: the genital tract or

in the labor room or in maternity operation

Late-onset: this is caused by the organisms thriving in externally
 The infection is often transmitted by the care givers.
The predisposing causes of LOS are :
 Lack of breast feeding
 Superficial infections
 Aspiration of feeds
 Disruption of skin integrity with needle pricks and use of IV fluids
 External env of homes or hospital.
Clinical features:
• The manifestations of neonatal sepsis are often vague and nonspecific
demanding high index of suspicion for early diagnosis.
• Any altertion in feeding patterns
• Active baby suddenly becoming lethargic
• Hypothermia in preterms and fever in term babies
especially in association with gram positive infections and
meningitis.

 Diarrhea, vomiting and abdominal distention

 Jaundice and hepato-splenomegaly may be present

 Episodes of apneic spells with cyanosis may also be one of

the sign.

Neonatal Sepsis Management:

 The infant should be managed in a thermo neutral env and

started on intravenous antibiotics
 Nursing Management

 Hand washing and thorough scrubbing with soap and water upto elbows for at least
2mons, gowning and change of shoes are mandatory.

§ Rings, bangles and wristwatches should be removed

§ Strict hand washing for 20 secs and use of antiseptic solution in between handling babies.

 Babies should be fed early and exclusively on breast milk.

Careful attention should be paid to hygiene of the katori and spoon.

 The umblical stump should be left open. Local application of spirit reduces colonization.

 All procedures should be done wearing mask.

 Unnecessary needle pricking should be avoided.

 Strict housekeeping routines for washing , disinfection, cleaning of cots/incubators should

be ensured .
 Infants of diabetic mothers IDM

Clinical manifestations of IDM

 Large for gestational age

 Very plump and full faced

§ Abundant vernix caseosa

§ Plethora

§ Listlessness and lethargy

§ Large placenta and umblical cord

§ Possibly meconium stained at

birth
 Therapeutic management

 The most common management of IDMs is careful

monitoring of serum glucose levels and observation for

accompanying complications such as RDS.

 Studies confirm that maintaining blood glucose level more

than 50mg/dl prevent serious neurological conditions.

 Oral and IV backup may be titrated to maintain adequate

blood glucose levels.

 Nursing care management

§ Early introduction of carbohydrate feedings as appropriate

§ Serum glucose monitoring.

§ Because macrosomic infants are at high risk for problems

associated with difficult delivery, they are monitored for birth
injuries.

§ There is some evidence that IDMs have an increased risk of

acquiring type 2 DM during childhood or early adulthood
therefore a nurse should also focus on healthy lifestyle and
prevention later in life with IDMs.
 VOMITING

        Vomiting is one of the common manifestations in the neonates. Regurgitation after

feeds should not be confused with vomiting. Mucus vomiting often hinged with blood is quite

common soon after birth. It is due to irritation often gastric mucosa by the swallowed

materials during birth.

Causes:

· Dietic
        

· Over feeding
        

· Excessive air swallowing

        

· Intracranial injuries
        

· Infective gastroenteritis, meningitis, septicemia

        

· Obstructive
        

o Gastro-intestinal obstruction
       

o Oesophageal atresia
       

o Pyloric stenosis
       

o Cardiospasm
       

o Duodenal atresia
       
Clinical Manifestation
· Electrolyte fluid imbalance
        

· Weight loss
        

· Tachycardia
        

· Hypovolemia
        

· Dehydration
        

· Metabolic change (Hypernatraemia, Hypocalcemia)

        

· Fatigue
        

· Tachypnoea
        

Diagnostic evaluation
        The newborn that have persistent vomiting must be
carefully evaluated to determine the cause.
The diagnostic evaluation is:

· History from parents

        

· Physical examination
        

· Laboratory test
        

· X-ray
        

· Daily checking of weight, urinary output etc

        

Management

Medical management

        Vomiting is only a symptom of illness and management is corrected towards detecting

and treating the cause.

1. Parenteral fluid and electrolyte therapy may be indicated to correct the resulting
   

dehydration and alkalosis.

2. Anti-emetic drugs may be given to control vomiting eg. Stemetil, domstal, emset, perinorm.
   

3. In case of obstruction the child should be given nothing by mouth and aspiration by
   

nasogastric tube is necessary.

2. DIARRHOEA IN NEWBORN

        The frequent passage of stool in the newborn is known as diarrhea.

Causes of Diarrhoea

        The main causes of diarrhea

· Infective gastroenteritis
        

· Parenteral
        

· Dieteric
        

Infective

· E.coli
        

· Staphylococcus or virus
        

· Artificially fed babies

        

· Using uncleaned utensils

        

Clinical Manifestation

· Frequent watery stools

        

· Generally green and containing mucus and blood

        

· Colic and screaming

        

· Dehydration
        

· Sunken eyes
        

· Depressed anterior fontanella

        

· Circulatory collapse
        
Parenteral

        The common infective organisms are;

· E-coli
        

· Echovirus
        

· Rotavirus
        

Systemic Infections like;

· Septicemia
        

· Bronchopneumonia
        

· Phelitis
        

· Meningitis
        

Dietic

Patient is maily

· Quantitative
        

· Qualitative
        

QUANTITATIVE

Over feeding

        Increased amount or frequent feeds lead under irritation of the gut and intestinal hurry causing diarrhea. The stool is bully with

out any mucus.

Under feeding

        It is called hunger diarrhea. There is frequent passage of small green stools

Qualitative

· Excessive carbohydrate
        

· Excessive fat
        

· Protein diarrhea
        
Prevention

· Maintaining asepsis of the utensils used

        

· Maintenance of the regularity and adjusting the amount of

        

feeder

· Increasing the quantity of the feed as guided by test feeding

        

Nursing Management

· Provide psychological support to the parents

        

· The baby should be isolated

        

· Check the vital signs and skin changes frequently

        

· Assess the characteristics of diarrhea and recording of the

        

number amount and consistency of stools

· Check the colour of the stool

        
· Check the smell of the stool, if any faul smell is present that
        

indicates infection

· Collect the stool from the diaper by using a sterile stick and send
        

the stool for laboratory examination

· Educate the mother to wash baby’s cloth and dry it in the sunlight
        

· General hygienic care should be provided like baby bath, change

        

the soiled diaper etc

· Keep the perineal area clean and dry

        

· Administer drug as per physicians order

        

· Educate
         the mother about prevention of diarrhea home

management of diarrheal disease, importance of ORS, dietary

management hygienic practices, medical help etc

3. UMBILICAL SEPSIS

        The causative organisms are staphylococci E.coli or any pyogenic

organism.

Clinical Features

· Umbilical discharge
        

· The base of the cord stump look moist

        

· The periumbilical skin becomes red and swollen

        

· Pyrexia
        

· Features of toxemia or jaundice

        

Spread of Infection

· Periumbilical cellulites with suppuration

        

· Thrombo – phlebitis of the umbilical vein with extension of the infection to

        

the liver

· Peritonitis
        
Prevention

· Antiseptic and aseptic precaution should be given

        

· The cord is to be inspected once more for evidence of slipping of

        

ligature

· If the cord is left exposed to the air without any application of dusting
        

powder it dries up and force off much earlier

Nursing Management

· To provide proper care of the cord at birth

        

· The cord should be cut with the sterile precautions

        

· The stump and the base of the umbilical stump should be cleaned
        

daily and when contaminated with the spirit swab

· The cord should be kept dry and free from contamination

        

· Clean the umbilical area either with betadine or with spirit

        
4. OPHTHALMIA NEONATORUM

        It is defined as inflammation of conjunctiva during first three weeks of life.

Etiology

· Chlamydia trachomatis
        

· Bacterial
        

· Chemical
        

· Viral
        

Mode of Infection

        This infection mainly occurs during delivery by contaminated vaginal discharge.

Clinical features

Discharge from the eyes it may be;

· Watery
        

· Mucopurulent to frank purulent in one or both eyes

        

· The eyelids may be sticky or markedly swollen

        

Investigations

        The discharge is taken for;

· Gram stain smear

        

· Culture and sensitivity

        

· Scraping material from lower conjunctiva

        

· Culture is special viral media

        
Prevention

· Vaginal discharge during the antenatal period should be treated

        

· Maintained aseptic techniques at birth

        

· New born baby’s closed lids should be thoroughly cleansed and dried
        

· Sulphacetamide eye drop or soframycin eye drop is instilled in to each eye for a few days
        

Nursing Management

· Baby should be isolated

        

· Check the vital signs frequently

        

· Observe for the clinical manifestations

        

· Instillation of chlormphenicol eye drops or neomycin according to doctors order is used

        

to clear the infection

· Eye drops should be kept separate for each baby

        

· The mother should be free from gonorrhoea infection

        

· Prophylactic eye drops should be used if infection suspected

        

· For severe infections systemic antibiotic therapy in addition to local treatment may be
 

prescribed by the doctor

5. ORAL THRUSH

        Infection of the buccal mucous membranes and the tongue by the

Fungus candida albicans is not uncommon specially in bottle fed babies.

Mode of infection

· Feeding bottle
        

· Teats
        

· Nurses hand
        

· Mother nipple
        

        Oral thrush usually appear in the late first week or during the second

week.

Clinical Features

· The infant refuses to take feeds

        

· The patches are visible on the mouth

        

· Spots on the edges of the tongue are diagnostic

        
Prevention

        Maternal fungal infection in the vagina is to be adequately treated

before delivery.

· Utensils including feeding bottles and teats are to be properly cleaned

        

before and after each feed

· The baby’s mouth should not be rubbed vigorously with gauze

        

Nursing Management

· Observe for the clinical manifestation

        

· Maintain nutritional status

        

· Hand washing is necessary before feeding to the baby

        

· Avoid contact with infected infants

        

· Feeding bottles and teats are to be properly cleansed before and after
        

each feed.
 MINOR DISORDERS OF NEWBORN AND MANAGEMENT

Molding

•         The head may appear asymmetric in the newborn of a vertex birth.

•         Caused by the overriding of the cranial bones during labor and

birth.

•         Diminishes within few days after birth.

•         Head moulding
Telangiectati nevi

•         Pale pink or red spots frequently found on the eyelids, nose, lower occipital

bone and nape of the neck.

•         More noticeable during the periods of crying.

•         Fade by the second birthday.

•         Telangiectati –stork bite

Stuffy nose

 It may lead to mouth breathing and

 excessive air swallowing which may lead to Abdominal distention and vomiting.

Management :

•         The nostrils may be cleansed with cotton soaked with normal saline.
Forceps and Vacuum marks

•         Reddened areas over the cheeks and jaws.

Disappear with in 1 or 2 days.

•         Vacuum extractor suction marks on the scalp.

•         No treatment is necessary

Sticky eyes

•         It may be due to a chemical irritant or bacterial conjunctivitis

due to Staphylococcus.

•         Erythromycin (0.5%) ointment every 6 hrs for 7-10 days.

Subconjunctival hemorrhage

•         Found on the sclera

•         Caused by the changes in vascular tension or ocular pressure

during birth

•         Remain for a few weeks

•         Reassure the parents

Oral Thrush

•         1% gentian violet solution or nystatin suspension, applied

to each side of the mouth with a cotton swab 3-4 times a day.

•         Oral thrush/ Epsteins pearls

Milia

•         Exposed sebaceous glands, appear as raised white spots

on the face, especially across the nose.

•         No treatment is necessary, because they clear up

spontaneously with in the first month

Erythema toxicum

•         Perifollicular eruption of lesions that are firm, vary in size from 1

to 3mm and consist of white  or pale yellow papule or pustule with an

erythematous base. It is often called newborn rash or flea bite

dermatitis.

•         No treatment is necessary. Disappear in a few hours or days.

Napkin rash

•         More common in artificially fed babies.

•         It can be prevented by frequent care and attention to the napkin

area along with immediate changes of the napkins after each soiling.
Perianal dermatitis

•         It is situated around the anal opening. It is due to the alkalinity

of the stool and also seen in artificially fed babies.

•         Management: Use of lactose, instead of glucose.

Congenital phimosis

•         Pinpoint prepuce which makes the baby cry during the act of

micturition.

•         Management: dilatation by mosquito forceps.

Pseudo menstruation

•         Thick, whitish mucus vaginal discharge which is tinged

with blood.

•         Caused by the withdrawal of maternal hormones

Smegma

•         White cheese like substance is often present between

the labia
Physiological jaundice

•         This is observed in 60% of term and 80% of preterm neonates.

•         Occurs after the first 24 hours of life.

•         Resolves with hydration and frequent feedings

Constipation

•         It is commonly met in artificially fed babies.

Management

•         Correction of the diet and extra water is usually effective.  If it

fails, milk of magnesia 4ml by mouth is effective.

Mangolian spot

•         Macular areas of bluish black or gray- blue pigmentation on the dorsal

area and the buttocks.

•         Fade during the first or second year of life.

Nevus flammeus

•         Port wine stain

•         Red to purple area of

dense capillaries

•         Commonly appears on

the face

•         Cosmetic cream
Nevus vasculosus

•         Strawberry mark

•         Raised, clearly declined, dark red, rough surfaced birth mark usually found in the

head region

•         It resolves spontaneously

NURSES ROLE FOR PREVENTION OF NEONATAL PROBLEMS

·   Screen out high risk babies and liberal use of elective L.S.C.S in case of

contracted pelvis, cephalo pelvic disproportion or malpresentation.

·     In normal delivery the nurses should check the following

   Continuous fetal monitoring to know fetal distress
 Episiotomy should be done carefully to prevent injury to the scalp
   Neck should be unduly stretched while delivery the shoulders 

· Preterm baby should be delivered with episiotomy and forceps application special

care in preterm delivery

    To prevent anoxia

    To avoid strong sedation

     To administer vit k 1mg injection prevent or minimize haemorrhage

·   Difficult forceps and never apply traction during the forceps delivery

· Proper selection and special care should be give while conducting breech delivery
·         Prevent intracranial injury by never be hasty during delivery of head,
episiotomy should be done to minimize head compression and contrasted
delivery of head by forceps.
·        Trunk should not be pulled one side
·        Limbs are delivered in a manner and not simply by pulling them out
·        Gentle traction in the proper direction is applied
·        Gentleness in the maneuver and fraction in the proper direction to
prevent injuries to the born
·        The nurse who have upper respiratory tract infection should not
conduct delivery
·        Immediate care of the new born should be given to prevent baby from
hypothermia/infection
·        Unnecessary exposure of the baby should be prevented
·        Reassurance the parents about the common problems of neonates
and its prevention
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