Pediatric Nursing

NURSING CARE OF HIGH RISK OR

SICK NEWBORN
A. The newborn in the first day of life
B. High risk Newborn
1. Problems related to maturity
a. Prematurity
b. Post maturity
2. problems related to gestation weight
a. Small for gestational age (SGA)
b. Large for gestation age (LGA)
3. Acute conditions of the neonates such as:
a. Respiratory distress syndrome
b. Meconium aspiration syndrome
c. Sepsis
d. Hyperbilirubinemia
e. Sudden death syndrome (SIDS)

4. Newborn at risk due to maternal infection

a. Ophthalmia neonatorum
b. Hep B virus
c. HIV infection
d. Infant of a drug dependent mother
e. Infant with fetal alcohol exposure
 OBJECTIVES:
At the end of this chapter the students should be
able to:
1. Discuss the assessment of high risk newborn and
determine whether safe transition to extrauterine life has
occurred.
2. Discuss the newborn priorities in the first day of life.
3. Define the common classifications of high-risk infants and
describe common illnesses that occur in these
classifications of newborns
4. Discuss the diagnosis of these common illnesses
5. Discuss the interventions appropriate for these illnesses
and be able to point out the rationale of each intervention
NEWBORN PRIORITIES IN THE FIRST
DAY OF LIFE
• Initiating and Maintaining respirations
• Establishment of extrauterine circulation
• Maintenance of fluid and electrolyte balance
• Control of body temperature
• Intake of adequate nourishment
• Establishment of waste elimination
• Prevention of infection
• Establishment of infant-parent/caregiver relationship
• Institution of development care, or care that balances
physiologic needs and stimulation for the best development.
 INITIATING AND MAINTAINING
RESPIRATIONS
• An infant who has difficulty accomplishing effective
respiratory action yet survives may experience residual
neurologic difficulties because of cerebral hypoxia.
• If respiration does not begin immediately, respiratory
acidosis increases in amount so much that the blood pH
and bicarbonate buffer system can fail.
• An additional concern that ineffective respirations create is
the failure of the ductus arteriosus to close.
• Infant is forced to use serum glucose quickly and so may
become hypoglycemic, compounding the initial problem
even further
Review of
the
Fetal
Circulation
FACTORS PREDISPOSING INFANTS TO RESPIRATORY
DIFFICULTY IN THE FIRST FEW DAYS OF LIFE
• Low birth weight • Meconium staining
• Intrauterine growth • Irregularities during labor
restriction • Cord prolapse
• Maternal history of • Low APGAR score (<7) at
diabetes 1 or 5 minutes
• Premature rupture of • Small for Gestational Age
membranes • Breech birth
• Maternal use of • Multiple birth
barbiturates and narcotics
• Chest, heart, respiratory
close to birth
tract anomalies
• For all these reasons, resuscitation is important for
both infants who fail to take a first breath and for
those who have difficulty maintaining adequate
respiratory movements on their own.
 Resuscitation should follow an
organized process:
1. establish an airway
2. expand the lungs
3. initiate and maintain effective ventilation
4. cardiac massage (only if respiratory
depression is severe and heart rate is < 100
beats/min)
 Video you tube
• Resuscitation of newborn infants
 Drug Therapy
• Few medications are necessary for newborn
resuscitation
• Epinephrine 1:10,000 may be administered
intravenously to stimulate heart action
• Surfactants may be given to preterm infants
to replace the natural surfactant that has not
yet formed in their lungs
 Ventilation Maintenance
• Babies with difficulty establishing respirations at birth
need to be carefully observed in the next few hours to
be certain that respirations are maintained.
• Oxygen saturation should remain adequate
• Newborn should be placed under warmer, to prevent
cooling and acidosis
• Positioning of infant on the back with head of mattress
elevated approximately 15 degrees
• Additional suctioning is done if necessary
• Determination of the cause of the distress so that
appropriate intervention may be given
 Establishing Extrauterine
Circulation
• If no heartbeat, chest massage should be started
• Lung ventilation at a rate of 30 times per minute should be
continued and interspersed with the cardiac massage at a
ratio of 1:3
• Continue to monitor pulse oximetry to evaluate respiratory
functions and cardiac efficiency
• Intravenous epinephrine to stimulate heart action may be
prescribed
• Then transfer infant to high-risk nursery for continuous
cardiac surveillance to be certain cardiac function is
maintained
 Maintaining Fluid and Electrolyte
Balance
• Intravenous 10% Dextrose water to restore
their blood glucose level. Sodium, glucose, &
potassium level are added as needed
according to electrolyte laboratory results
• Isotonic solution (usually normal saline) may
be administered to increase blood volume
• A vasopressor such as Dopamine may be given
to increase blood pressure and improve cell
perfusion
 REGULATING TEMPERATURE
• Keep newborns in neutral-temperature
environment, one that is neither too hot nor too
cold because doing so places less demand on
them to maintain a minimal metabolic rate
necessary for effective body functioning
• Cover newborn with infant cap, wiping body and
head dry, and using radiant warmer or pre-warned
incubator, or skin-to skin contact with one of the
parents, plastic wraps/shields, or warmed
mattresses, and no body contact with cool
equipment like tables or x-ray scales etc.
 ESTABLISHING ADEQUATE
NUTRITIONAL INTAKE
• Intravenous fluid as a temporary source of
nourishment
• Gavage feeding may be introduced
• Gastrostomy for long term nutritional concern
• Breastmilk should be given to infant through
gavage feeding if infant can not suck
• Pacifiers may be given to infant during feeding
times
 Establishing waste
elimination
• Elimination (voiding and passing of stool) of
these infants may occur later.
• Carefully document any voiding/bowel
movement that occur during resuscitation,
because this is a proof that hypotension is
improving and kidneys are being perfused.
 Preventing Infections
• High-risk babies have an increased
vulnerability to contract infection
• Nurses’ goals should be on the prevention of
nosocomial infections (handwashing, strict
infection precaution)
• Maintain breastfeeding to increase immune
system of baby
Establishing Parent-Infant Bonding
• Be certain that parents are kept informed of what is
happening during resuscitation at birth.
• Let parents visit the unit as often as possible. Urge them to
spend time as much as possible.
• Be certain that parents have continuing access to
personnels after discharge so they can care confidently of
the infant at home
• One nurse as the consistent caregiver and information
provider to avoid confusion of parents
• If infant died, let parents view the infant without being
covered with equipment.
The NEWBORN at risk because of
altered gestational age or birth
weight
 The preterm infant
• live-born infant born before the
end of 37 weeks of gestation
• late preterm (34 to 37 weeks) and
early preterm (24 to 34 weeks)
• Common factors associated with
preterm birth:
– Low socioeconomic level
– Poor nutritional status
– Lack of prenatal care
– Multiple pregnancy
– Previous early birth
– Race (nonewhites have higher
incidence)
• Common factors associated with preterm birth:
– Cigarette smoking
– Teenage pregnancy
– Order of birth (early birth is highest)
– Closely spaced pregnancies
– Abnormalities of the mother’s reproductive system
– Maternal Infection (specially UTI)
– Pregnancy complications ( early rupture of
membrane, premature separation of placenta)
– Early induction of labor
– Elective caesarean birth
Assessment
 Assessment
• Very little flexion in the upper and lower extremities
• Minimal or absent recoil of extremities
• Positive for scarf sign. Premature infant’s elbow will reach near or
across the midline
• Positive heel to ear. Premature infant’s demonstrate little resistance
• Few plantar creases
• Breast tissue. The premature infant’s areola and nipple are barely
visible
• Ears of preterm infants are very flat, relatively shapeless
• Male genitalia. Testes are very high in the inguinal area and there
are very few rugae in the scrotum
• Female genitalia. Clitoris is very prominent, the labia majora are
small and widely separated
Little flexion of upper and lower extremities/
minimal or absent recoil of extremities
Scarf Sign. Premature infant’s elbow will
cross midline
Few plantar creases
 Impaired gas exchange related to
immature pulmonary functioning
• Health care team should be prepared with
pre-term size laryngoscope, endotracheal
tubes, suction catheters and synthetic
surfactants
• Keep infant warm
• Procedures should be carried out gently
• Continued oxygen administration but with
extra caution
Risk for deficient fluid volume related to
insensible water loss at birth and small
stomach capacity
• Intravenous fluids should be given
continuously through infusion pumps
• Monitor babies weight, fluid intake and urine
output, specific gravity and electrolytes
• Blood glucose determination is done as well
 Risk for imbalanced nutrition, less than body
requirements related to additional nutrients
needed for maintenance, rapid growth,
suckling difficulty and small stomach

• Feed preterm infant more frequently with

small amounts
• Have feeding schedule
• Gavage feeding as ordered
• Breastmilk feeding
 Ineffective thermoregulation
related to immaturity
• Radiant warmer
• Skin-to-skin contact to mother/father
• Keep infant dry
• Do not let baby come in contact with cool
surfaces
 Risk for infection related to
immature immunity defence system
• Linens and equipment used for the preterm
infant must NOT be shared with other infant
patients
• Staff must be free from any infection and
observation of handwashing and gloving and
gowning regulations must b strictly enforced.
 Risk for impaired parenting related to
interference with parent-infant attachment
resulting from hospitalization of infant at birth

• Encourage parents to begin interacting with the infant as soon as

possible.
• Help parents air feelings of disappointment or guilt will develop a
more positive attitude toward their pre-term infant
• Allow parents to stroke or handle baby before and after gavage
feedings. Allow parents to participate in the simple procedures.
• Make sure parents have the chance to see their baby if there are
cases of transfer to other wards or regions. Photographs and
snapshots may be helpful.
• Encourage them to visit even at a distant site as often as possible.
• Parents may still keep in touch through phones or
nursery e-mails, photos sent through celfone camera
• Support/ assist parents who are visiting their infant but
are afraid that they may “wrongfully “touch any gadget
or equipment.
• There should be only one information provider to the
parents to avoid confusion because parents may become
baffled hearing from several different personnels for
information
• Encourage siblings to visit too, however, be certain that
the siblings do not have upper respiratory tract
infections or fever, updated with immunization and have
not recently exposed to communicable diseases
 The post term infant

• Born after 41st week of pregnancy

• Dry, cracked , leatherlike skin from lack of fluid, and
absence of vernix, may be meconium –stained;
fingernails may have grown well, demonstrates
alertness like 2-week old baby
 Nursing interventions
• Obtain sonogram to measure biparietal diameter of
the fetus
• Nos-stress test or complete biophysical profile to
establish placental function
• Prepare for possible resuscitation
• Regulate temperature
• All post term infants need follow-up care until at least
school age to track developmental abilities because the
lack of nutrients and oxygen in utero may have left
them with neurologic symptoms that will not become
apparent until they attempt fine-motor tasks.
SGA vs LGA
Small-for-Gestational-Age infant
• Also called microsomia
• Birth weight is below the
10th percentile on the
intrauterine growth curve
for the age
• Small for their age because
they have experienced
intrauterine growth
restriction (IUGR) or failed to
grow at the expected rate
 Etiology
• lack of adequate nutrition for the mother during
pregnancy (adolescents are prone to having a high
incidence of SGA infants)
• Placental anomalies
• Placenta did not obtain sufficient nutrients from the uterine arteries
• Placenta is inefficient at transporting nutrients to the fetus
• Placental underdevelopment
• Placental damage
• Maternal systemic diseases that decrease blood flow to
the placenta
• Gestational hypertension
• Diabetes mellitus
• Women who smoke heavily or use opiates
Assessment
 Assessment
• Fundal height during pregnancy is less than
expected, however, it should be confirmed by
sonogram
• Biophysical assessment, nonstress test,
placental gradient, amniotic fluid amount are
diagnostic procedures to provide additional
information
 • Below average in weight,
Small-for- height and head
circumference
Gestational Age • Wasted appearance with poor
infant’s appearance skin turgor and appears to
have large head with skull
sutures widely separated
• Hair may be dull and
lustreless
• Liver may be small, abdomen
is sunken and umbilical cord is
dry and yellow-stained
• May have better developed
neurologic response, sole
creases and ear cartilage, and
is unusually alert and active
 • High hematocrit level
Small-for-Gestational
• Increase in total
Age infant’s number of red blood
Laboratory Findings cells, thus increased
blood viscosity and
prolonged
acrocyanosis, and
thrombus formation
may result
• Hyperbilibirunemia
may also result
• hypoglycemia
 Ineffective breathing pattern
related to underdeveloped body
systems at birth
• Prepare for possible resuscitation at birth
• Closely observe both respiratory rate and
character in the first few hours of life.
• Proceed with neonatal resuscitation as
indicated
 Other nursing diagnoses
• Risk for ineffective thermoregulation related
to lack of subcutaneous fat
• Risk for impaired parenting related to child’s
high risk status and possible cognitive and
neurologic impairment from lack of nutrients
in utero
The Large-for-Gestational-Age Infant
• Also termed
macrosomia
• Birthweight is
above 90th
percentile on
an intrauterine
growth for the
gestational age
• “big baby
syndrome”
 Assessment
• May show immature reflexes and low scores in gestational
age examination in relation to their size
• May have extensive bruising or even birth injury during
delivery
• May have prominent caput succedaneum, cephalhematoma
or moulding
• Polycythemia may occur
• Hyperbilirubinemia may result due to breaking of extra red
blood cells
• May have poor heart function due to transposition of great
heart vessels, assess for cyanosis
• Assess for possible hypoglycemia
 Nursing Diagnoses and Related interventions

• Ineffective breathing pattern related to possible birth

trauma in the LGA newborn
• Identify the injury (broken clavicle or diaphragmatic paralysis due to
increased ICP)
• Proceed with resuscitation if indicated with appropriate precautionary
measures
• Risk for imbalanced nutrition , less than body
requirements, related to additional nutrients needed to
maintain weight and prevent hypoglycemia
• Feed newborn immediately afterbirth to prevent hypoglycemia.
Evaluate carefully the intake at this feeding so you won’t overestimate
its ability to suck
• May give supplemental feeding formula to supply enough fluid and
glucose for the first 24 hours
 Respiratory Distress Syndrome
• Infant respiratory distress syndrome (IRDS),
also called neonatal respiratory distress
syndrome (NRDS), respiratory distress
syndrome of newborn, or increasingly
surfactant deficiency disorder (SDD), and
previously called hyaline membrane disease
(HMD), is a syndrome in premature infants
caused by developmental insufficiency of
pulmonary surfactant production and
structural immaturity in the lungs.
 Assessment
• Difficulty initiating • Cyanosis
respirations • Fine rales and
• Low body temperature diminished
• Nasal flaring breathsounds
• Sternal and subcostal • Seesaw respirations
retractions • Heart failure
• Tachypnea • Pale gray skin
• Cyanotic mucous • Periods of apnea
membranes • Bradycardia
• Expiratory grunting • pneumothorax
• Chest x-ray will reveal a diffuse pattern of
radiopaque areas that look like ground glass
(haziness) in the lungs
• Blood gas study will reveal respiratory acidosis
 Therapeutic Management
• Surfactant replacement
• Oxygen administration
• Ventilation
• Additional Therapy
• Supportive Care
• Preventive Nursing
• Dating pregnancy by sonogram and documenting the level of
lecithin
• Use of tocolytic agent such as magnesium sulfate to prevent
pre-term birth
• Glucocorticosteroid injections to hasten formation of lecithin
 Meconium Aspiration Syndrome
• An infant may aspirate meconium either in
utero or with the first breath at birth
• It may cause severe respiratory distress
through:
• Inflammation of bronchioles
• Mechanical plugging of bronchioles
• Decreases surfactant production
• These three result to hypoxemia, carbon dioxide
retention, intrapulmonary and extrapulmonary shunting
can occur, pneumonia
Assessment
• Can have difficulty
establishing respirations
• Low Apgar Score
• Tachypnea, retractions
ad cyanosis
• Barrel chest because of
air trapped
• Pulse oximetry will
reveal poor gas
exchange
 Therapeutic Management
• Amnioinfusion
• CS if deeply stained
• Suctioning with a bulb or syringe may be done while baby
is still at the perineum.
• Do not administer oxygen under pressure
• Antibiotic therapy
• Surfactant may be administered
• High inspiratory pressure if necessary
• Observe infant for signs of heart failure
• Maintain neutral temperature
• Chest physiotherapy with percussion and vibration
SUDDEN INFANT DEATH SYNDROME
(SIDS)
• Sudden unexplained death in
infancy
• Tends to occur higher in
adolescent mothers, infants of
closely spaced pregnancies,
underweight and preterm infants
• Prone to SIDS infants are with
bonchopulmonary dysplasia,
twins, native american infants,
alaskan native infants,
economically disadvantaged black
infants, and infants with narcotic
dependent mothers
 Contributory factors are:
• Sleeping prone
• Viral respiratory or botulism infection
• Exposure to secondary smoke
• Pulmonary edema
• Brain stem abnormalities
• Neurotransmitter deficiencies
• Heart rate abnormalities
• Distorted familial breathing patterns
• Decreased arousal responses
• Possible lack of surfactant in alveoli
• Sleeping in a room without moving air currents
 Management
• Counseling for parents. Same
counsellors periodically do follow-up
visits
• Let the parents and family go through
the grieving process. Just make self
available to queries and clarifications
• Give autopsy reports to reduce guilty
feelings of parents
 Rh Incompatibility
• If mother’s blood type is RH (D) negative and the fetal blood
type is Rh positive (contains the D antigen), this introduction
of fetal blood causes sensitization to occur and the woman
to begin to form antibodies against D antigen.
• The active exchange of fetal-maternal blood as placental villi
loosen and the placenta is delivered. This causes surge in
antibody formation after a pregnancy, --and in the second
pregnancy, there will be a high level of antibody already
circulating in the woman’s blood stream. This will then act to
destroy the fetal red blood cells in the next pregnancy if the
new fetus is Rh-positive, leading to the fetus being severely
compromised by the end of the next pregnancy
Erythroblastosis fetalis
Case of erythroblastosis fetalis
 Therapeutic Management
• Rho immune globulin (RHIG or RhoGAM)
(passive Rh antibodies) within 72 hours after
birth of an Rh+ baby. The process of antibody
formation will b halted and sensitization will
not occur.
 ABO incompatibility
• This happens when mother is blood type O
and the fetal blood type is A; it may occur also
when the fetus has type B or AB. Type B has
the most marked reaction
• Hemolysis of the blood begins with birth when
blood and antibodies are exchanged during
the mixing of maternal and fetal blood as the
placenta is loosened; destruction may
continue as long as 2 weeks.
Assessment
• Liver and spleen may be
enlarged in attempt to destroy
damaged red blood cells
• Extreme edema (hydrops
fetalis, means lethal state of
edema)
• Heart failure due to severe
anemia
• Jaundice which is progressive
during the first 24 hours of life,
resulting to hyperbilirubinemia
• Progressive hypoglycemia
• Decreased hemoglobin
 Therapeutic Management
• Initiation of early feeding
• Early feeding stimulates bowel peristalsis and helps to
eliminate stool. The sooner bowel elimination is
initiated, the sooner bilirubin removal begins
• Phototherapy
• Light supplied by phototherapy appears to speed
conversion potential of the liver
• Nursing responsibilities during phototherapy
• Exchange Transfusion
• Infant’s blood is drawn from the umbilical vein and
then replaced with equal amounts of donor blood
Phototherapy
• Phototherapy is indicated if serum
bilirubin level rises to 10-12mg/dl at 24
hours age
• Place light 12-30 in. above bassinet or
incubator
• Cover eyes of infant, check cover
frequently
• Diaper to cover genitalia
• Assess for stool and urine output
(amount and color)
• Monitor for infant’s axillary
temperature
• Assess skin turgor and intake and
output
• Allow mother-infant bonding
• Common health
problems that
develop during
INFANCY
 Common health problems that develop
during Infancy
• Physical and Developmental Disorders of the Gastro Intestinal System
– Cleft lip and palate
– Esophageal Atresia and tracheoegeal fistulas
– Hirchsprung’s disease,
– Intussusception
– Imperforate anus

• Nervous system
– Hydrocephalus
– Neural tube defects
– Infections of the nervous system

• Skeletal system
• Talipes disorders
• Developmental Hip Dysplasia
 Physical and Developmental Disorders of
the Gastro Intestinal System
• Cleft lip and palate
• Esophageal Atresia and tracheoegeal fistulas
• Hirchsprung’s disease,
• Intussusception
• Imperforate anus
Cleft lip
• Failure of maxillary and
median nasal processes to
fuse between weeks 5 and
8 of intra uterine life
• In varying degrees from
single small notch to total
separation o the lip, upper
teeth, floor of nose and
absent gingiva
• More prevalent among
boys than girls
• Highest incidence among
Asian population
 Cleft lip
• Appears to be caused by the transmission of
multiple genes aided by teratogenic factors
present during weeks 5 and 8 of intrauterine
life such as viral infections, certain seizure
medicines (phenytoin), maternal smoking or
binge drinking, hyperthermia, stress and
maternal obesity, folic acid deficiency
Cleft palate
• An opening of the palate occurs
when the palatal process does not
close as usual at approximately
weeks 9 and 12 of intrauterine life
• Incomplete closure is usually at the
midline but may involve anterior
hard palate and the posterior soft
palate
• Like cleft lip, it appears to be the
result of polygenic inheritance or
environmental influences
• Tends to occur more frequently in
girls
 Assessment
• May be detected by sonogram while an infant
is in utero
• Readily apparent on inspection of the mouth
• Assess child for other congenital anomalies as
well.
 Therapeutic Management
• May be repaired while still in utero, but not usually attempted
• May be repaired surgically shortly after birth, usually between
2-12 weeks of age, then nasal rhinoplasty to straighten deviated
nasal septum may be necessary at age 4-6 years.
• Malek protocol: surgery may be a two-stage palate repair, 3
months old for the soft palate repair, then 6 months old for the
hard palate repair
• Follow-up treatment by a pediatric orthodontics for tooth
realignment
• Follow-up hearing or speech difficulty as well
• Interprofessional team setting would be excellent (pediatric
dentists, audiologists, speech pathologists, geneticists,
craniofacial surgeons)
 Risk for imbalance nutrition, less than body
requirements, related to feeding problem caused by cleft
lip or palate
• The best feeding method for the baby with cleft lip and palate is to
support the baby in an up-right position, and feed the infant gently
using a soft bottle and a commercial cleft lip nipple or a spoon
• Breastmilk is still encourage for feeding through breast pump
• Sips of fluid between feedings can help keep the mucous membranes
moist and prevent cracks and fissures that could lead to infection
• Be sure that infant is burped well after each feeding
• A bottle that is soft and squeezable may be used to help the baby in
sucking
• If surgery will be delayed beyond 6 months of age and solid food
should be introduced to baby, advise parents to feed baby with soft
foods
 Post-operatively
• NPO for 4 hours, then introduced to fluids such as plain
water. Begin process with only small amount each time
to prevent vomiting.
• Only fluids are allowed for feeding for 3 to 4 days post-
operatively, no milk yet, then soft diet follows until
healing is complete.
• Be sure to give child sips of clear water to flush tiny
particles of food from the suture line and keep as clean
as possible
• Prevent tension on suture line, prevent crying, prevent
vomiting. Use a specialized feeder when feeding.
• Give analgesic to decrease inflammation and pain
• To avoid crying , anticipate the infant’s needs
• Help parents use measures to pacify baby like rocking, carrying,
or holding, that are necessary to make infant secure and
comfortable
• No hard or sharp must come in contact with a recent cleft suture
line
• Watch out that infants do not put toys to mouth
• Do not use straw to drink, or toothbrush to clean their teeth.
Use paper cups for drinking instead of glass/tin/har plastic
• Keep elbow restraints in place as necessary so they do not put
fingers in the mouth and poke or pull at the sutures
• Divert child’s attention off the suture line, so they don’t run their
tongue over the suture lines
• Teach parents on dosage of pain relievers, and keep suture line
protected until suture line is complete
Risk for ineffective airway clearance related
to oral surgery

• Observe child closely during the post operative

period for respiratory distress
• Suction mouth to remove mucus, blood and
unswallowed saliva. Be careful and gentle so catheter
will not touch suture line.
• Place child on side position to allow mouth
secretions to drain forward. Do not put child on
prone position.
• A logan bar may be used to hold suture line in place
Risk for infection related to surgical incision
• Clean suture line with sterile water or saline
with sterile cotton-tipped applicators after
every feeding, or whenever the natural serum
that forms on suture line and accumulate
• Do not rub suture line, use a smooth, gentle
rolling motion to avoid loosening sutures
Risk for impaired parenting related to birth of
an infant who is physically challenged
• Allow parents and child to interact
• Caution mother that breastfeeding infant post-
operatively takes time before the baby learns to
suck effectively
• Understand the parents on how they feel. The
negative feeling they have towards the child is
normal, and this will help them begin to deal
with such emotions.
• Referral to support groups is highly advisable
Risk for situational low self esteem related
to child’s facial surgery
• Child needs some help in adjusting to their new
appearance, like the scars, until a second cosmetic
repair can be completed later in life.
• Reinforce child’s other positive attributes,
emphasizing that the scar is just one small aspect
of who they are
• As children reaches adolescence, the nurse may
need to review familial inheritance pattern of cleft
lip, so they are aware of possible risk of
transmission to their own children
Risk for ear infection related to altered slope
of Eustachian tube with cleft palate surgery

• Watch out for signs of infection such as fever pain,

pulling on an ear, disharge from an ear
• Remind parents the importance of reporting
pharyngeal infections to care providers promptly so
it can be treated before the infection spreads to the
middle ear
• Myringotomy if necessary is performed
• Routine screening for hearing loss during childhood
is necessary and it should be explained to parents
 Impaired verbal communication related to
cleft palate
• Plastic prosthesis may be used to cover the
incomplete palate
• Training by speech therapist while preschooler
• Blowing games like blowing feather or tennis
ball to exercise mouth to pronounce “p” and
“b”
Devices used to feed infants with
cleft lip and/or palate
Cleft lip and palate surgery
Esophageal Atresia and tracheo-esophageal
fistulas
• Oesophageal atresia is the incomplete
formation of the oesophageal lumen, resulting
in the proximal oesophagus forming a “blind
pouch” which does not connect to any other
structure
• Tracheo-esophageal fistula occurs when an
opening develops between the closed distal
oesophagus and the trachea
 Assessment
• Hydramnios in utero
• Detected during the first feeding: infant will cough,
become cyanotic, and have obvious difficulty of
breathing as fluid is aspirated
• So much mucus in mouth and infant appears to be
blowing bubbles
• If passing a catheter through the mouth, the catheter
doesn’t pass through, and is detected through x-ray,
with the catheter coiled
• Barrium swallow and bronchial endoscopy examination
reveal the blind-end esophagus and fistula
 Therapeutic Management
• Put infant in upright position, 60 degree angle so acid of stomach acid does
not go to the lungs, acid stay in the stomach through the use of gravity
(sitting the baby in an infant chair)
• Insertion of NGT and connected to low intermittent suction
• Gastrostomy and insert a tube
• IVF and parenteral nutrition is started to prevent dehydration and
electrolyte imbalance
• IV medications to restrict stomach’s ability to produce acid
• Antibiotic therapy may be prescribed to prevent infection
• Surgical treatment: anostomoses of ends, and closing the fistula, this will be
stages of surgeries. Post-operatively, observe infant closely 7 to 10 days post-
op, for possible leakage of fluids and air into chest-cavity
• Some stenosis or stricture remains, esophageal dilatation at periodic
intervals may be done to keep the repaired esophgaus fully patent if
necessary
• Check for the presence of other congenital anomalies
 Risk for imbalance nutrition , less than body
requirements, related to inability to take in
oral feedings

• Early introduction of oral fluids may help ensure patency of

the esophagus because it helps adhesion of anastomosis site
• If formula is given through the gostrostomy tube, introduce
it into the tube slowly and allow it to run by gravity pressure
only to prevent fluid from entering the esophagus and
preventing pressure on the new suture line
• Allow sucking pacifiers
• Breastmilk feeding is encouraged… tell mother to express
milk for the gastrostomy feeding
• Teach parents how to do gastrostomy feeding
Risk for infection related to aspiration or
seepage of stomach secretions into lungs

• Pre-operatively: keep child in sitting position, assist with

cervical esophagostomy,; keeping infant in radiant
warmer with high humidity oxygen to maintain body heat
and liquefy bronchial secretions. Prevent child from
crying so air will not enter stomach from the trachea
• Post-operatively: anticipatory teaching about how the
baby will look post-op is important for the family to keep
them from being overwhelmed upon seeing the baby
• Observe for respiratory distress
• Continue to suction saliva from the mouth as
prescribed
• Turning child frequently prevents secretions to
accumulate; turn face to side to drain secretions
out
• Humidified Oxygen helps keeps secretions moist
and not stagnant
• Keep laryngoscope and endotracheal tube readily
available at the bedside in case extreme edema
develops, which may increase the infant’s risk for
airway obstruction
Hirschsprung disease
 Hirschsprung (HERSH-sproong) disease
• affects the large intestine (colon) of newborns,
babies, and toddlers. The condition — which prevents
bowel movements (stool) to pass through the
intestines due to missing nerve cells in the lower
part of the colon — is caused by a birth defect. Most
of the time, the problems with passing stool start at
birth, although in milder cases symptoms may appear
months or years later.
• This prevents the colon from relaxing, which can
cause a blockage of digested material and make it
difficult to pass stool.
• Hirschsprung disease can affect the entire large intestine,
which is called long-segment disease, or it can affect a shorter
length of the colon closer to the rectum (short-segment
disease). It's more common for nerve cells to stop
developing closer to the rectum, since in the womb cells
develop on a pathway that starts at the top of the large
intestine and ends at the end, near the rectum. (So, with
Hirschsprung disease, nerve cells just stop developing while
on that pathway.)

• Hirschsprung disease is about five times more common in

males than females. Children with Down syndrome and
genetic heart conditions also have an increased risk of
Hirschsprung disease.
Signs:
– inability to pass stool within the first or second
day of life
– swollen belly, bloating, or gas
– diarrhea
– vomiting, which may include vomiting a green or
brown substance
– Inability to pass stool within the first 48 hours of
life is often the key to detecting Hirschsprung
disease in a newborn. This red flag can be very
valuable in diagnosing the condition.
• Less severe cases of Hirschsprung disease may go
unnoticed until later childhood, or sometimes even
adolescence or adulthood. Symptoms may include:
• abdominal swelling
• constipation
• difficulty gaining weight
• vomiting
• gas
• Because Hirschsprung disease can affect the body's
ability to absorb nutrients, growth may be delayed
in older kids who have it.
 Diagnosis
• barium enema. Barium is a dye that is put into the colon using an
enema. The barium shows up better on X-rays and can help
doctors get a clearer picture of the colon. (In kids with
Hirschsprung disease, the intestine usually appears too narrow
where the nerve cells are missing.)
• suction biopsy. This test, which can often be done in the office,
involves using a suction device to remove some cells from the
colon's mucous lining. This test will reveal whether nerve cells are
missing and can help make the diagnosis of Hirschsprung disease.
• manometry or a surgical biopsy. Manometry is a test in which a
balloon is inflated inside the rectum to see if the anal muscle
relaxes as a result. If the muscle doesn't relax, the child may have
Hirschsprung disease. In a surgical biopsy, the doctor removes a
sample of tissue from the colon to examine under a microscope.
 treatment

• The most common surgery to correct Hirschsprung disease

involves removing the section of the colon without nerves and
reattaching the remaining portion of the colon to the rectum.
Often, this can be done through minimally invasive
(laparoscopic) surgery immediately after the condition is
diagnosed.

• In some cases, the doctor may do the surgery in two steps. In the
first step, the doctor will remove the unhealthy portion of the
colon and then perform a procedure called an ostomy. In an
ostomy, the doctor creates a small hole, or stoma, in the child's
abdomen and attaches the upper, healthy portion of the colon to
the hole.
• the two types of ostomy are:
• Ileostomy: removing the entire large
intestine and connecting the small intestine
to the stoma
• Colostomy: removing just a portion of the
colon
– The child's stool passes through the stoma into a bag that is
connected to it and needs to be emptied several times a day.
This allows the lower part of the colon to heal prior to the
second surgery. In the second surgery, the doctor closes up
the hole and attaches the normal portion of the colon to the
rectum.
• After surgery, a high-fiber diet can ease and
prevent constipation for older children. Drinking
plenty of water is also important, and helps
prevent dehydration. The large intestine helps
absorb water from food, so dehydration can be a
concern for children who have had part of their
intestine removed.

• observe for signs of enterocolitis, (such as

explosive and watery diarrhea, fever, a swollen
belly, or bleeding from the rectum) and refer
immediately
 Imbalanced nutrition, less than body
requirements, related to reduced bowel function
• Pre-operatively, minimal residue diet is offered to
older children, stool softeners, vitamin supplements
and daily enemas until their condition improves
• Total parenteral Nutrition can offer source of
nutrition
• Teach parents on how to choose low residue diet;
fried foods and spicy highly seasoned foods are
totally omitted
• Postoperatively, observe infant for abdominal
distention
• Assess for bowel sounds and observe passage of
flatus and stools
• NGT can be removed as soon as peristalsis is
observed (burborygmic sound is heard)
• Child may be offered small frequent feedings of
fluids such as water and gelatin.
• The gradually introduce full fluids, broth, soft
diet, minimal residue diet, and finally normal
diet for child’s age
Intusscusception
• medical condition in which a part of the intestine folds into the
section next to it. It involves the small bowel
• Symptoms include abdominal pain which may come and go,
vomiting, abdominal bloating, and bloody stool
• It often results in a small bowel obstruction. Other complications
may include peritonitis or bowel perforation.
• Risk factors in children include certain infections, diseases like cystic
fibrosis, and intestinal polyps.
• Diagnosis is often supported by medical imaging.in children
• Intussusception is an emergency requiring rapid treatment.
Treatment in children is typically by an enema
• If enema is not successful surgery is used
• Dexamethasone may decrease the risk of another episode
• occurs more commonly in children than adults. In children, males
are more often affected than females.
• The usual age of occurrence is six to eighteen months old.
• Early symptoms can include periodic abdominal pain, nausea,
vomiting (sometimes green in color from bile), pulling legs to
the chest area, and intermittent moderate to severe cramping
abdominal pain.
• Later signs include rectal bleeding, often with "red currant jelly"
stool (stool mixed with blood and mucus), and lethargy.
• Physical examination may reveal a "sausage-shaped" mass, felt
upon palpating the abdomen. Children, or those unable to
communicate symptoms verbally, may cry, draw their knees up
to their chest, or experience dyspnea (difficult or painful
breathing) with paroxysms of pain.
• Fever is not a symptom of intussusception. However,
intussusception can cause a loop of bowel to become necrotic,
secondary to ischemia due to compression to arterial blood
supply. This leads to perforation and sepsis, which causes fever.
• An x-ray of the abdomen may be indicated to
check for intestinal obstruction or free
intraperitoneal gas. The latter finding implies
that bowel perforation has already occurred.
Some institutions use air enema for diagnosis,
as the same procedure can be used for
treatment.
• The condition is not usually immediately life-threatening.
The intussusception can be treated with either a barium or
water-soluble contrast enema or an air-contrast enema,
which both confirms the diagnosis of intussusception, and
in most cases successfully reduces it. The success rate is
over 80%. However, approximately 5–10% of these recur
within 24 hours.
• Cases where it cannot be reduced by an enema or the
intestine is damaged require surgical reduction. In a surgical
reduction, the surgeon opens the abdomen and manually
squeezes (rather than pulls) the part that has telescoped. If
the surgeon cannot successfully reduce it, or the bowel is
damaged, they resect the affected section. More often, the
intussusception can be reduced by laparoscopy, pulling the
segments of intestine apart with forceps.
Imperforate anus
• a birth defect that
happens while baby is
still growing in the
womb.
• baby has an improperly
developed anus, and
therefore can’t pass
stool normally from
their rectum out of
their body.
• It occurs more often in boys than girls. The
rectum, bladder, and vagina of a female baby
with an imperforate anus sometimes share one
large opening. This opening is called a cloaca.
• The condition develops in the womb during the
5th to 7th weeks of pregnancy. The cause is
unknown. Many times babies with this condition
also have other defects of the rectum.
• Doctors usually can diagnose this condition
shortly after birth when the doctor or nurse
takes rectal or anal temperature upon birth
 Signs and Symptoms
• no anal opening
• no stool in the first 24 to 48 hours of life
• stool passing through the wrong place, such
as the urethra, vagina, scrotum, or the base of
the penis
• a swollen abdomen
• an abnormal connection, or fistula, between
your baby’s rectum and their reproductive
system or urinary tract
• This condition almost always requires surgery. Multiple
procedures are sometimes necessary to correct the problem.
A temporary colostomy can also allow baby time to grow
before surgery.
• The type of corrective surgery needed will depend on the
specifics of the defect, such as how far baby’s rectum
descends, how it affects the nearby muscles, and whether
fistulas are involved.
• A pull-through operation is when your baby’s surgeon pulls
the rectum down and connects it to the new anus.
• To prevent the anus from narrowing, it may be necessary to
stretch the anus periodically. This is called anal dilation. You
may need to repeat this periodically for a few months. Your
doctor can teach you how to perform this at home.
 Imbalance nutrition less than body
requirements related to bowel obstruction
and inability to take in fluids
Pre operative
• Keep the infant NPO to avoid further distention
of bowel
• NGT attached to low suction for decompression
• IVF and TPN will maintain fluid and electrolyte
balance
Post op
• Small oral feedings of glucose water ,
formula or breastmilk can be started after
NGT will be removed
• Low residue diet (rice cereals and strained
fruits and vegetables, avoid high-fiber
 Impaired tissue integrity of rectum
related to surgical incision
• No rectal temperature taking
• No enemas or suppositories (or any procedure through anus)
• Prescribe stool softeners
• No diaper put on infant… only under baby’s buttocks
• Clean suture lines after each bowel movement
• Irrigate with normal saline solution
• Side lying or supine is best position
• Teach parents how to do digital dilatation 1-2x a day for few
months to prevent constriction (to maintain patency until the
incision heals)
• Daily stool softener is prescribed
End of topic