Neonatal Assessment and Care (Part 3) PDF - 2024

SN3180 – Childbearing Family Nursing BSN 3 Neonatal Assessment and Care (Part 3) Dr. Shirley Lo School of Nursing The Hong Kong Polytechnic University 2024  1 2...

SN3180 – Childbearing Family Nursing BSN 3 Neonatal Assessment and Care (Part 3) Dr. Shirley Lo School of Nursing The Hong Kong Polytechnic University 2024  1 2 3 Major neonatal Nursing care and Neonatal nutrition, adaptations assessments screening and others ▪ Physiological adaptations ▪ Immediately after ▪ Nutritional needs delivery (delivery ward) ▪ Neurological / ▪ Neonatal screening behavioural adaptions ▪ Subsequent assessment ▪ Neonatal jaundice (postnatal ward) Normal newborn: Needs and Care ▪ Aims of nursing care: ▪ Maintain a neutral thermal environment ▪ Identify physical problem & abnormal functions ▪ Promote hydration & nutrition ▪ Protect from injury & infection ▪ Enhance parental knowledge & skills on newborn care ▪ Encourage parent-infant bonding ▪ Observation ▪ General appearance, e.g. cyanosis, respiration, response, muscle tone ▪ Vital signs – Q6-8H : To, AR, RR, BP (only when indicated) ▪ Skin - rash, septic spots, jaundice, sore buttock ▪ Eyes - discharge ▪ Nose - blocked nostrils, running nose ▪ Mouth - oral thrush (Candida) ▪ Cord - bleeding, signs of infection, ▪ Nutrition, feeding behavior, tolerance of feeds, BW ▪ Elimination (urine & stool) ▪ Sleep-wake pattern ▪ Maintain warmth ▪ Dried completely, room / incubator temp, adequate clothing, avoid unnecessary exposure ▪ Promote parent-infant bonding: rooming-in 24h/day (WHO, 2013) ▪ Nutrition & hydration ▪ Breastfeeding ▪ Initiate breastfeeding within 1/2 hour after birth & ▪ Feed on demand ▪ Encourage exclusive breastfeeding up to age of 6 months if possible ▪ Formula-feeding # ▪ First bottle feed can start 3-4 hs post delivery (during the 2nd reactivity period when the newborn is awaken and appear hungry) ▪ ~8 feeds / day, Q3H intervals Nutritional needs of newborns & ▪ Healthy term infant: Caloric intake 100-115 kcal/kg/day for the first month (~50-55 kcal/lb/day), and then dec. to 85-95 kcal/kg/day from 6-12 months ▪ Infants receive energy from: fat (50%); carbohydrate (40%); protein (6-8%) ▪ Breast milk or formula can provide ~20 kcal/oz - ▪ Stomach capacity inc. rapidly: up to 60-90ml by the end of 1st week ▪ Fluid needs: 140-160 ml/kg/day E ▪ Feeding patterns – length of each feed may vary, newborn may take up to an hour ▪ supplementary water is- not recommended routinely < 6 months - - ▪ Physiological weight loss due to meconium, extracellular fluid: - ▪ ~ 3.5% of BW in the first 3-4days; ▪ breastfed (less fluid intake) infants may loss up to 7% of BW (but not more than 10% loss) ▪ Regain weight by D5, reach or above birth weight by D 10-14 ▪ Weight gain in the first 4 weeks: 1 oz/day at 1 month, in, general gain ~5-7 oz/week ▪ Insufficient calories may increase the risk of tissue breakdown, losing weight, dehydration, delayed growth & development How much milk does an infant need daily? ▪ Every infant is unique … so follow their feeding cues (especially BF) ▪ Average newborn ~3.6kg requires 541-600ml/day (i.e. 45-75ml/feed, Q2-3H if on formula) O C ▪ Frequency: first few days: Q2-3H; 1-2 months old: Q5-6H ▪ Amount: ▪ 1 month – about 550-970ml/day (formula milk) - ▪ 2-5 months – about 630-1110ml - - https://www.fhs.gov.hk/english/health_info/child/12146.html Signs of dehydration in the newborn: ▪ Depressed fontanels ▪ Rapid, weak pulse ▪ Elevated low-grade temperature ▪ Dark, concentrated urine ▪ Elevated urine specific gravity (1.020) [normal range: 1.008-1.010] ▪ Dry, hard stools ▪ Dry skin with little turgor  Early initiation of breastfeeding Breastfeeding within first 0.5-1h after birth Early suckling provides warmth, security and colostrum that is a newborn’s first immunization Increase duration of breastfeeding gradually Take advantage of the first (golden) hour of alertness https://www.who.int/multi-media/details/5- interesting-facts-about-breastfeeding Hand expression of colostrum ▪ Mothers should be coached on how to express colostrum & breastmilk as a means of maintaining lactation in the event of their being temporarily absence ▪ Mothers of infants admitted to neonatal intensive care unit should be supported to enable them to have skin-to-skin contact when the baby’s conditions stabilized  Stages of human milk: Colostrum – the initial milk that begins to be secreted during mid- pregnancy and is immediately available to the baby at delivery. Mature milk – presents contains high level of lactoferrin by 2 weeks postpartum and IgA; and continues until also has a laxative effect lactation ceases. It contains 87% water Transitional milk – still yellow in and 13% solids (fats, color like colostrum but is more copious and contains more fat, protein and lactose, water-soluble vitamins and carbohydrates). calories. Composition of breastmilk (1) ▪ 87% water ▪ 13% solid ▪ Fat – brain development, hormone, cell membrane ▪ Provides 50% calories, mostly triglycerides, easily digested ▪ Varies during a feed: 3-5 times higher in hindmilk ▪ Contains cholesterol & essential fatty acids (Omega-3 & Omega-6) for vision & brain growth ▪ Long-chan polyunsaturated fatty acids: DHA, ARA (retina, brain & other neural tissues growth) ▪ Vitamins ▪ Directly related to the mother’s vitamin intake ▪ Vitamins A, E & C are high, but Vit. D is low ▪ Breastfed infants of vegan mothers may need B12 supplement Composition of breastmilk (2) ▪ Protein: ▪ High level of taurine (brain development & bile conjugation) ▪ Easily - digested: with a higher ratio of whey : casein (esp in early lactation) ▪ Less likely to cause allergies : So c 20W ▪ Carbohydrate ▪ Mainly in the form of lactose, provides energy to the brain development ▪ Enhance absorption of Ca, Mg, and Zinc ▪ Inc. intestinal acidity and dec. pathogen growth ▪ Minerals ▪ Iron – enough to up to 6 months ▪ Cow’s milk – higher sodium, calcium and phosphorus: cause high renal solute ▪ Enzymes ▪ Pancreatic amylase & lipase – aid digestion  Online Composition of breastmilk (3) material ▪ Immunologic advantages: hbin ▪ Bifidus factor – promotes growth of Lactobacillus bifidus, protects from intestinal pathogens ▪ Leukocytes – macrophages secrete lysozyme (bacteriolytic) and lactoferrin (binds iron in iron-dependent bacteria, iron in milk is absorbed easier) ▪ IgA – represents over 90% of milk antibodies, protects the GI ▪ IgG – activates phagocytes, anti-inflammatory activity ▪ IgM – protects against pathogens via opsonization (bind to the surface of the antigen) of Gram-negative bacteria ▪ The changing concentration of human milk immunoglobulins (read the *online self- study material)  ✓ I may have 8-12 breastfeeding every day! ✓ I have at least 6 wet single-use nappies ✓ My poo poo is unformed and plentiful ✓ I am growing according to the growth standards … Further details about breastfeeding: Guest Lecture on Nov 9, 2024! C Lam, 2018 97 ▪ Elimination ▪ Pass urine/meconium within 12-24 hrs after birth 1st 24hrs Day 1-2 Day 3-4 Day 5 Urine ≥1 1-2 3-4 ≥5 Stool ≥1 1-2 ≥2 Vary (Family Health Service, 2016) ▪ Hygiene ▪ Care of eyes ▪ clean with sterile NS/water, or boiled cool water ▪ Cord care (refer to lab 2A) ▪ keep clean & dry ▪ dry within 1-2 hours of birth ▪ Shrived & blackened by day 2-3 ▪ Should slough off within day 7-10  ▪ Hygiene ▪ First bath may be delayed to at least 24 hs after birth (WHO, 2017) ▪ Keep the umbilical stump clean and dry (refer to Lab 2A) Current practice: Delay bathing until 24 hours after birth or at least 6 hours of life (if there is cultural Before: needs) Bathe a newborn within the first hour Why? of life to remove 1) … blood, meconium, 2) … vernix and any other 3) … infectious substances Vernix Caseosa – the creamy / cheese-like substance on newborn’s skin has anti-microbial and moisturizing qualities that help to protect newborns in their new extra-uterine environment remove with olive oil ▪ Skin care ▪ Prevention of diaper rash ▪ change diaper when wet/soiled ▪ wash/clean buttock with warm water each time after bowel open ▪ if skin is red, don't rub, gently dab the area with soft wet cloth ▪ keep buttock air dry if skin is really red, try leaving diaper off during a nap ▪ ±apply protective cream/zinc oxide diaper cream with prescription ▪ Prevention of infection ▪ unable to form antibodies until ~2 months (that’s why most immunizations are given after 2 moths old) ▪ e.g. umbilical cord care, preparation of breast/bottle feeds; wash hands before handling newborn  Starting from the 2019-20 school year, eligible female students will receive the first dose of 9- valent HPV at Primary 5. They will receive the 2nd dose when they reach Primary 6 in the next school year https://www.fhs.gov.hk/tc_ch i/main_ser/child_health/chil d_health_recommend.pdf  Newborn Screening in Hong Kong ▪ Congenital hypothyroidism ▪ Glucosse-6-phosphate dehydrogenase (G6PD) deficiency ▪ Hearing loss of certain enzyme Adituency ▪ Inborn Errors of Metabolism (IEM) ▪ Pilot SCID screening since Oct 2021 (QEH and QMH) Congenital Hypothyroidism (CH) Incidence 1:4000 lives birth in Hong Kong S/S: No obvious symptoms Prolonged jaundice, large tongue & hoarse voice, inactivity, constipation, poor feeding, poor weight gain, delayed motor development Untreated congenital hypothyroidism may lead to irreversible intellectual disabilities & growth failure Aetiology Congenital lack of thyroid gland, deficient TSH secretion, anti-thyroid medications, iodine deficiency Neonatal screening Collection of 2.5ml cord blood at birth, or on D5 if cord blood is not available Send to Central Genetic Neonatal Screening Unit (mostly at the Children Hospital) Re-evaluate on D5 if TSH ≥ 15 mIU/L Results: normal, or abnormal or borderline (since 2021) Treatment: lifelong daily thyroxine supplement, regular follow-up  - Glucosse-6-phosphate Dehydrogenase (G6PD) Deficiency ▪ X-linked hereditary disease caused by deficiency of enzyme (maintain stability of red cell membrane) fragility & easy breakdown of RBC Neonatal jaundice (NNJ) ▪ Symptoms: ▪ sudden rise of body temp. and yellow coloring of skin and mucous membrane ▪ Dark yellow-orange urine ▪ Pallor, fatigue, general deterioration of physical conditions ▪ Heavy, fast breathing ▪ Weak and rapid pulse ▪ Precipitating factors for acute hemolysis ▪ Medications ▪ Antipyretics, e.g. Aspirin ▪ Antibiotics, e.g. Nitrofurantoin, Nalidixic acid, Sulfamethoxazole ▪ Antimalarial drugs, e.g. Primaquine ▪ Antispasmodics, e.g., Phenazopyridine ▪ Chinese herbal medicine ▪ e.g. Rhizoma Coptidis, Flos Chimonanthi Praecocis, Flos Lonicerae, Calculus Bovis, Margarita ▪ Broad/fava beans ▪ Mothballs (Naphthalene) G6PD Deficiency Prophylactic measures Neonatal screening Placental cord blood sent to Central Genetic Neonatal Screening Unit for quantitative assay of G6PD activity Deficient Borderline Normal 205 µmol/L=12 mg/dl in a full term baby on day 3) ▪ Increase of indirect (unconjugated) bilirubin ▪ The peak of total serum bilirubin occurs usually on day 3-4 (day 5-7 for a preterm baby) ▪ The decrease in total serum bilirubin level is progressive and it is usually completed by the 14th day after birth (21st day for preterm babies) ▪ Excluding from other pathological causes Porter 2002 WHO 2002, 2003 Kumar 1999  Causes of Physiological jaundice ▪ Jaundice can be physiological in newborn due to the following reasons: ▪ Massive erythrocyte destruction ▪ Decreased conjugation rate ▪ Poor transformation of bilirubin ▪ In pre-term newborns ▪ Jaundice occur earlier, peak & last longer than term baby ▪ Hemolysis occur in same rate as term infant with even shorter RBC (30-40 days) ▪ Common causes: ▪ Delay feeding ▪ Immature gut function with slow peristalsis ▪ Albumin binding capacity affected by hypoglycemia, hypoxia, acidosis, hypothermia & hypoproteinaemia ▪ Immature liver to deal with large amount of bilirubin for conjugation Porter 2002 NICE 2010 Breastfeeding jaundice ▪ also called suboptimal intake jaundice ▪ most often occurs in 1st week when BF is being established ▪ inadequate intake leads to increased reabsorption of bilirubin in the intestines ▪ inadequate milk intake also delays the removal of meconium which contains large amount of bilirubin ▪ more feedings can reduce the risk of jaundice Breastmilk jaundice ▪ Occurs in 3-5% of breastfeeding newborns, mostly in 2nd week or later ▪ This type of jaundice can explain the persistence of a “physiological jaundice” for several weeks (up to 3 months) ▪ Cause unknown, but Pregnanediol (a breakdown product of progesterone) in breast milk may depress / inhibit the action of glucuronyl transferase (the enzyme converts indirect bilirubin to the direct form). Pregnanediol remains in breastmilk for only 24-48 hs, therefore, discontinuing breastfeeding is not necessary ▪ Do not need any treatment except for high bilirubin level, then phototherapy may be used Porter 2002 NICE 2010 Management of baby with physiological jaundice: The baby has the characteristic of physiological jaundice - is in good clinical condition: active, good suckling reflex and normal temperature, no other pathological signs - Jaundice appears after 24-36 hours of life - Visual inspection of jaundice Baby can be discharged from the hospital If the baby is in hospital, re-asses every 8-12 hours for first days Plan for follow up; use transcutaneous bilirubin check whenever available Train the mother to look for problems and tell her how to take care of her baby: e.g. early feeding, stimulate gut mobility, more glucose to facilitate liver enzyme (reassure mother) Breastfeeding should be maintained Pathological jaundice Suspect it when: ▪ Jaundice in the first 24 hours after birth (or 2 day of life for pre-term baby) ▪ At any time “severe jaundice”= the baby has yellow palms and soles ▪ Recurrent of initially treated jaundice ▪ Infection, hypothermia or any other danger sign (but baby’s condition may also be satisfactory) ▪ Other additional criteria: ▪ There is a rapid elevation of the total serum bilirubin ▪ >85.5 µmol/L/day = 5 mg/dl/day ▪ Direct (conjugated) bilirubin level is ▪ >34 µmol/L (2 mg/dl), or ▪ ≥20% of total serum bilirubin level ▪ The jaundice lasts >14 days (> 21 days in pre-term baby) WHO 2002, 2006 & 2013 Porter 2002 Prevention of NNJ Obtaining serum bilirubin ▪ Neonatal screening ▪ Cord blood for G6PD deficiency, T4 & TSH ▪ Efficient care of newborn to prevent hypothermia, dehydration … ▪ Early detection of NNJ ▪ Close monitoring of newborns ▪ Serial SB checking, use of transcutaneous bilirubinometer (TCB), do not rely on visual examination to assess the level of jaundice Use of transcutaneous bilirubinometer Management of NNJ ▪ Phototherapy ▪ Term baby, BW > 2500g, SB > 250 mmol/L ▪ Term baby, BW < 2500g, SB > 204 mmol/L ▪ Preterm start at lower SB ▪ Exchange blood transfusion ▪ Term baby, SB > 340 mmol/L ▪ Preterm: start at a lower SB ▪ Phenobarbitone: stimulate hepatic glucuronyl transferase activity ▪ Treat underlying causes Phototherapy ▪ Unconjugated bilirubin in skin & superficial capillaries is converted to water-soluble form via blue-green fluorescent light placed at a distance of 30-50 cm, or fibreoptic mat (cold light) / blanket placed on / under infant’s body ▪ S/E: hypo-/hyperthermia, dehydration, retinal damage, skin rash, loose stool / diarrhea, bronze baby syndrome ▪ Nursing care: ▪ Maximize baby’s skin exposure to the light * ▪ Cover only the eyes, care of eyes and eye shields annsaim- A ▪ Regular turning, monitor body temp. ▪ Vital sings and SB monitoring ▪ Extra fluid may be needed to compensate increased insensible fluid loss (10ml/kg) Preparing for discharge ▪ health education is important due to the shortening of hospital stay ▪ client-centered approach ▪ advise on safe home environment – e.g. baby with G6PD deficiency ▪ ensure essential baby care items are ready ▪ provide information of helping resources: breastfeeding hotlines, MCH services / card; follow-up arranged ▪ Maternal and Child Health Centre (MCHC) ▪ Immunization ▪ NNJ follow-ups ▪ Postnatal checkup ▪ Family planning  how to do assessment References how a why uterine thundas American College of Obstetricians and Gynecologists. (2017). Delayed umbilical cord clamping after birth. Available at: https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2020/12/delayed- umbilical-cord-clamping-after-birth.pdf palpate Ballard, J. L., Khoury, J. C., Wedig, K., Wang, L., Eilers-Walsman, B. L., & Lipp, R. (1991). New Ballard Score: Expanded to include extremely premature infants. Journal of Pediatrics, 119(3), 417-423. Centers for Disease Control and Prevention (2021). Breastfeeding. Available at: https://www.cdc.gov/breastfeeding/index.htm Davidson, M,, Lond, M., & Ladewig, P. (2020). Chapter 27-29, Old’s Maternal-newborn nursing and women’s health across the lifespan (10th ed.). Boston: Pearson. Department of Health, Hospital Authority, Baby Friendly Hospital Initiative Hong Kong Association, & La Leche League. (2015). Love starts from breastfeeding. Retrieved from http://www.fhs.gov.hk/english/health_info/child/20000.html Green, D.J. (2016). Maternal Newborn Nursing Care Plans (3rd ed.). Burlington, MA: Jones & Bartlett Learning Interprofessional Education and Research Committee of the Champlain Maternal Newborn Regional Program (CMNRP) (2013). Newborn thermoregulation: A self-learning package. Retrieved from http://www.cmnrp.ca/.../Newborn_Thermoregulation_SLM_2013_06.pd Any questions?