NEONATAL DISEASES

High Risk Newborn?

A newborn, regardless of gestational age or birth

weight, who has a greater than average chance of morbidity or mortality because of conditions or circumstances superimposed on the normal course of events associated with birth and the adjustment to extra uterine existence.
Greater chance of complications because of factors affecting Fetal development Antenatal period of mother Labour and birth.

Complications - unexpected and without warning.

CLASSIFICATION OF HIGH RISK NEONATES

Classified according to .
Etiological factors
Special care requirements Size

Gestational age

According to etiological factors

Low birth weight (LBW) infant
Infant who requires technological

support
The infant whose irreversible condition

will result in an early death.

According to special care requirements

Those requiring special or assistive

feeding techniques Those requiring respiratory assistance Those with complex congenital anomalies requiring supportive and assistive devices.

According to size
LBW Less than 2500 gm regardless of gest age MLBW 1501 2500 gm VLBW - <1500 gm ELBW - <1000 gm AGA/ AFD 10th 90th percentiles on intrauterine growth curves SGA/ SFD - <10th percentile on intrauterine growth curves (= IUGR) LGA/ LFD - > 90th percentile on intrauterine growth curves

According to mortality
Live birth Birth in which the neonate manifests any

heart beat, breathes or displays voluntary movement, regardless of birth weight

Fetal death - Death of fetus after 20 weeks of gestation

and before delivery, with absence of any signs of life after birth
Neonatal death Death in the first 27 days of life (Early

first 7 days)
Post natal death Deaths that occur at 28 days to 1 year Perinatal mortality Total no of fetal and early neonatal

deaths per 1000 live births

ORGANIZATION OF SERVICES FOR HIGH RISK NEONATES

Level I facility (Minimal care)

Can identify high risk pregnancies & high risk

neonates early Can implement emergency care in the event of complications 80% Newborns require minimal care Birth wt >2000 gm & Gest age > 37 wks Care at home, sub center or PHC Management of normal maternal & newborn care Care of newborns by mothers under supervision Basic care at birth, providing warmth maintaining asepsis, promoting breast feeding Traditional birth attendants can be trained

Level II facility
Dist hospitals, teaching institutions,

nursing homes Provides a full range of maternity and newborn care Equipped to manage the majority of maternal & neonatal complications 15 20% neonates Birth wt 1500 2000 gms, Gest age 32 36 wks Trained nurses and paediatricians Equipments For resuscitation, thermoneutral environment, IV infusion, gavage feeding, phototherapy, exch blood transfusion No compromise on adequate space, nursing staff, asepsis, care equipments

Level III facility

Apex institutions & regional

Perinatal centers Offers full range of maternal & newborn services of a level II facility Has capacity to provide care for the most complex neonatal complications Equipped with O2 & suction facilities, servo controlled incubators, vital sign & transcutaneous monitors, ventilators and infusion pumps etc 3 5% neonates Birth wt <1500 gms, gest age < 32 wks Skilled nurses and a full time neoatologist is on the staff

Transporting High Risk Newborn

Before birth - Intra uterine

transfer After birth Incubator transportation after stabilization ( warm, oxygenation/ intubation, vitals, O2 saturation, IV infusion as req) Transport team A neonatologist, a neonatal nurse, a resp therapist able to intervene as necessary

CARE OF HIGH RISK NEWBORN

Assessment
Apgar - Evaluation of cardiopulmonary & neurologic functions Constant observation Pulse-oximetry, elect, blood gases Detailed & ongoing record - of the infants condition Systematic assessment
Changes in behaviour, activity, SaO2, vital signs

Monitoring Physiological Data

TPR - in thermo-neutral environment
Have alarm systems (yet, compare

monitor readings with manual findings) Accurate I/O records Blood Glucose, Bilirubin, elect, Ca, hematocrit, gases (Imp - Record amt of blood drawn)

Respiratory support
Positioning & airway maintenance Suction - SOS Supplemental O2 Assisted ventilation

Thermoregulation
External warmth Servo-controlled incubator Radiant warmer 100 watt bulb Neutral thermal environment

Hydration
Supplemental parenteral fluids Add calories, elect & water Monitor fluid status by
Daily weights Accurate I/O record Urine examinations

Watch out for Hypo/ hyperglycemia

Nutrition
105 130 cal/kg/day for PT infants
Parenteral route (ELBW, VLBW,

critically ill) &/ Enteral route

Prevents jaundice

 Assessment during enteral feeds

Increased gastric residuals Abdominal distension Temperature instability Apneic episodes Bradycardia

 On the one hand, intensive care allows preterm infants to survive On the other hand, the treatment has many adverse consequences

Oh somebody Help!

PREPARATION FOR DISCHARGE

Parental education
Return demonstrations Routine child care activities Care in minor ailments Hand-outs/ Booklets on child care Parent rooming-in Follow up At Well baby clinic Telephonically

PRIMARY CAUSES OF NEONATAL DEATHS IN INDIA

CAUSE OF DEATH
1) BIRTH ASPHYXIA 2) IMMATURITY 3)INFECTIONS 4) CONGENITAL MALFORMATIONS

NUMBER PROPORTION
517 408 263 168 28.8% 22.7% 14.6% 9.3%

5)MISCLLEANEOUS

444

24.6%

1) Preterm new born The preterm newborn also known as the premature infant is the most common admission to neonatal intensive care unit (NICU). The immaturity places infants at risk for not only

neonatal complications (e.g. hyperbilirubinemia

and respiratory, distress syndrome) but also for other high risk factors (e.g. congenital anomalies

in association with prematurity).

Etiology of preterm baby

So many aspects however, concerning the exact high-risk cause of neonates are related to the incidence of prematurity prematurity is not known in most instances. The incidence of prematurity is lowest in the middle to high socioeconomic classes, in which pregnant women are generally in good health,

are well nourished and receive prompt and

comprehensive antenatal care.

The

incidence

is

highest

in

the

lower

socioeconomic class in which a combination of deleterious circumstances is present. Prematurity pregnancies, may be caused by multiple

Illness of mother (e.g. malnutrition, heart

disease, conditions) diabetes mellitus, or infectious

Hazards

of

pregnancy

itself,

such

as

Pregnancy induced hypertension (PIH),

 Placental abnormalities that may result in premature rupture of the membranes. Placenta previa (the placenta lies over the cervix instead of higher in the uterus) and

premature separation of the placenta.

1) Respiratory distress in newborn babies

Respiratory difficulties constitute the commonest

cause of morbidity in newborn babies. The clinical diagnosis of respiratory distress in the newborn is suspected when the respiratory rate is more than 60 per minute in a quiet resting baby and there are inspiratory costal recessions or expiratory

grunt.

Assessment of Severity of RDS The presence and intensity of cyanosis and its response to oxygen administration are useful indicators of gravity of the situation. Apart from taking blood pressure, palpation of peripheral

pulsations and color of the baby offers useful

information. The severity of RDS can be assessed by a simple clinical scoring system .

Table on Clinical respiratory distress scoring system Score 0 1 2 Respiration <60 60-80 >80 (rate/min) Cyanosis

None
room air

in No Cyanosis in Requiring
40% oxygen Mild Audible stethoscope Decreased

more

than 40% ambient oxygen Moderate to severe with Audible without stethoscope Barely audible

Retractions Grunting Air entry

None None Good

Causes :Symptoms complex secondary to a large number of etiological factors. Newborn

baby

has

limited

capacity

to

express

manifestations of a disease process. Identical responses are seen from a variety of disorders. Therefore identification of associated and predisposing conditions is important and

often crucial to make and etiolgic diagnosis of

respiratory distrees in newborn.

 PATHOPHYSIOLOGY OF

RESPIRATORY DISTREES SYNDROME

Diagnosis of RDS Septic screening and cultures should be taken to rule out infection. Reliance should be placed on radiological examination of chest to exclude life threatening malformations. Availability of facilities to monitor the status of arterial gases and acid base parameters is essential to assess the severity and prognosis of the disease process.

MANAGEMENT - Improve ventilation in order to enhance oxygenation correct acidosis provide thermoneutral environment

The goal of therapy is to maintain arterial pH

between. 7.35-7.45mm Hg.

cardiorespiratory monitoring oxygen therapy ventilation are required to improve the outcome.

a vital sign monitor and pulse oximeter for

continuous display of vital signs and arterial

oxygen saturation.

 Rectal or skin temperature hourly until stable and then 4 hourly Respiratory rate hourly or continuously Severity of retractions and grunting Status of peripheral pulses, capillary filling and blood pressure. Color Apneic episodes Activity, responsiveness and cry Urine output

INTRAVENOUS INFUSION

Required is guided by the weight use of

phototherapy and radiant warmers. Sodium bicarbonate 7.5 percent solution half diluted with distilled water. In seriously ill infants, umbilical arterial catheter should be inserted to obtain samples for acid base parameters and blood gases.

Oxygen : To relieve the cyanosis or to achieve the arterial paO2 between 50 to 80mm Hg or arterial oxygen saturation between 90% to 95%. Warmth and Humidity The skin temperature should be mainatained around 36.5C either by manually altering the temperature of the over head radiant warmer. Humidity should be maintained above 60 percent.

Antibiotics -

Ampicillin is the drug of choice.

Surfactant Surfactant therapy Most important Clinical advance in neonatal intensive care Useful both for prevention and treatment of RDS. Improves oxygenation by resolving atelectasis and improving lung compliance. Surfactant of human bovine (survanta, infasurf) or porcine (Curosurf) origin and two synthetic (Exosurf, DPPC / PG or ALEC) preparations are available.

Prognosis : It depends upon the nature of underlying condition causing RDS associated complications and quality of neonatal care. Outcome is extremely poor in HMD with a case fatality rate of 50 percent when adequate ventilator facilities are not available.

Respiratory system disorders The common condition in this group include Meconium aspiration Hyaline membrane disease massive pulmonary hemorrhage pneumothorax and congenital malformations. The respiratory distress of pulomary origin is characterized by tachypnea, marked intercostal retractions and expiratory grunt. Cyanosis is usually mild except in later stages of hyaline membrane disease and certain malformations.

Meconium aspiration syndrome

Meconium stained amniotic fluid occurs in 5 to 10 per cent of births. It generally occurs in term or post term newborns who are immature or small for gestational age.

Nursing Management Removed suctioning the oropharynx. Endotracheal tube insertion . Resuscitation at birth may be indicated Sodium bicarbonate may be given to correct

cyanosis and acidosis.

Outcome If treatment is not instituted promptly, meconium aspiration results in a significant number of neonatal deaths. The death rate of meconium stained infants is twice that of nonstained infants. The outcome for neonates who have aspirated meconium depends on the extent of central nervous system injury from anoxia both before and after birth.

ATELECTASIS IntroductionThe lungs are collapsed in fetal life, and the fetus receives oxygen through the maternal circulation. After birth, with the infant's first breath, the lungs normally expand to a variable degree. It may be several days before full expansion occurs. Atelectasis-imperfect expansion or collapse of lung tissue that carries air is found to a greater or lesser degree in almost all infants dying soon after delievery

Pathophysiology This condition may be either primary or secondary. In primary atelectasis the alveoli fail to expand initially. This is common in premature infants because of the immaturity of the diaphragm . It may also be due to oversedation of the mother before delivery. A mucus or meconium plug may cause atelectasis.

All infants are acidotic to some degree at birth, but in normal neonates the acidosis generally

corrects itself within the first 60 minutes of life.

In neonates whose lungs do not expand

normally, the acidosis becomes more , possibly

with pH values of below 7.0

Assessment
The major signs of primary atelectasis are poor respiratory effort poor air exchange, persistent cyanosis. The respiration are irregular, rapid, and shallow

 Cyanosis may be persistent or intermittent; it decreases if the infant cries or is given oxygen. (Congenital heart disease may also cause

cyanosis after birth, but this cyanosis increases

with crying and is relieved with oxygen administration

 The Apgar score is low. The signs of secondary atelectasis are usually those of the underlying respiratory problem.

When there is an obstruction causing the

atelectasis, the infant may have respiratory distress, cyanosis rapid deep breathing with retractions, and grunting.

Nursing Management Early recognition Clothing

Positioned so that the arms do not press or rest on the chest wall. Positioning the infant in a semi-Fowler position Suctioning and posturaL drainage Humidity

Outcome and prevention-the outcome for an infant or child with atelectasis depends on the cause of the condition. Prevention of premature labor, hyaline memberane disease, fetal and

neonatal anoxia and pneumonia as well as the

aspiration of foreign bodies by young children

would eliminate most causes of atelectasis.

4) Hyaline membrane disease (HMD)

Idiopathic respiratory distress syndrome or HMD is the commonest cause of neonatal mortality in preterm babies. Average overall incidence of HMD is about 10-15 per 1,000 live born affecting 10-15 percent of preterm babies. The incidence of HMD is inversely In the proportional west the to the gestational age. highest

incidence of around 60 percent is seen in infants

with a gestation age of 26 to 32 weeks.

Pathogenesis The lack of surfactant due to immaturity of lungs appears to be the basic abnormality. Deficiency of surfactant due to immaturity of lungs or its poor regeneration by damaged Type II alveolar cells. HMD appear to be due to hypoperfusion of the lungs leading to epithelial necrosis 'and transudation of plasma.

The lecithin / Sphingomyelin (L/S) Ratio amniotic fluid can be easily determined. A L/S ratio of 2 or more adequate lung maturity Less than 1.5 is often associated with hyaline membrane disease. Clinical triad of tachypnea, expiratory grunt and inspiratory retractions in a prematurely born asphyxiated infant. untreated diabetic mothers, severe Rhisoimmunization and those born by emergency cesarean section are prone to develop HMD

3 Grunting during expiration. 4) Serial gastric aspirate shake tests assess the status of pulmonary maturity .

5) MassivePulmonary Hemorrhage About to 10 percent of neonatal autopsies show evidences of massive pulmonary hemorrhage. Pathogenesis poorly understood Intrauterine growth retardation severe hemolytic disease of the newborn Twin gestation Congenital heart disease, sepsis, cold injury; perinatal distress factors. Born to a diabetic mother

It is characterized by Sudden apneic attacks Dyspnea associated with frothy blood welling through the nose and the oral cavity. Maintaining a clear airway, administration of fresh blood transfusion and fresh frozen plasma are recommended.

7)Transient
(TTNB)

Tachypnea

of

the

Newborn

Common among term babies born by cesarean section or precipitate delivery. Other risk factors include delayed cord clamping Macrosomia, male sex, excessive maternal sedation. It is also called as "wet lung syndrome"

or type II RDS.

Oxygen should be administered to maintain SaO2between 90% to 95%.

Oral feeds can be started when respiratory rate is less than 60/min.

Recurrent apneaIntermittent cyanosis associated with repeated protracted apneic episodes is generally known as recurrent neonatal apnea or apneic spells.

Apnea is defined as cessation of respiration for >20 seconds or cessation of respiration of any duration accompanied by bradycardia and/or cyanosis.
Important cause of mortality and brain damage in immature babies

PathophysiologyThe exact pathogenesis of recurrent apnea is uncertain. Ummaturity of medullary respiratory center with lack of effective respiratory drive appears to be the basic abnormality

Apnea central and obstructive

In central apnea, both the inspiratory effort and airflow cease simultancously and there are no movements of chest wall. Obstructive apnea is chracterised by absence of airflow despite having inspiratory efforts and movements of chest.

Causes :Predisposing factors : Raised environmental temperature, vigorous suction and sudden flexion of neck are common triggering factors. Immaturity Pulmonary conditions Cardiac malformations Neurological disorders Congenital anomalies Metabolic causes Infection Anemia

Assessment of the infant

Duration of apnea and its frequency presence or

absence of cyanosis and bradycardia should be

recorded.

The signs of raised intracraminal pressure e.g high pitched

cry, reflexes diminished general activity, poor feeding etc.

Investigations : Methemoglobin spot test . A drop of babys (patient) blood is placed on filter paper next to the one from a normal baby (control) and allowed to dry. In methemoglobinemia the blood spot will appear brown rather than the red .

General measure-Handling should be reduced to the bare minimum and infant should be nursed without a pillow.

Infant should preferably be nursed in a prone

position or kept in a supine position with slight

extension of neck.
Stimulation, Warmth, Oxygen.. Feeding- Infusion of 10 percent glucose solution till the apneic attacks are controlled

INFECTIONSInfections occur frequently in the neonate, causing illness and possibly death. Reasons : (1) the variety of organisms potentially present in the uterus , in the cervix and vagina during delivery, and in the environment of the hospital and community (2) immature host resistance that causes the neonate to be overcome by these organisms
(3) Difficulty in treating some infections because lack of specific therapeutic agent

PATHOPHYSIOLOGY 1) The agents that can cause infection in neonates include bacteria, viruses, protozoa, fungi, and Chlamydia and Mycoplasma organisms. 2) Transplacentally from a mother who has the

infection (congenital infection) or during

delivery from colonies of organisms .

2) Some neonatal infections can be avoided if

the mother receives treatment prior to or during pregnancy (syphilis and gonorrhea).

vaccine to preventive infection (rubella).

Neonates can also acquire nosocomial infections after delivery (postnatal infections) from other neonates,nursery personnel or contaminated supplies and equipment.

5)The smaller the neonate, the less resistance there is to infection. This is especially true in premature infants, who are more susceptible to generalized sepsis, meningitis, and urinary tract infections than are full-term neonates. The use of therapeutic procedures after birth (such as resuscitation, particularly if an endotracheal tube is used) and the use of an umbilical catheter or other invasive procedures increase the risk of infection.

NURSING MANAGEMENT Since organisms can be carried to neonates on the hands or under the nails or jewelry of caregivers, no one with a skin or other infection should enter the nursery or the rooms occupied by mothers. A mother who becomes infected should be isolated and, if there is any question of contamination, her neonate should be isolated from other infants in the nursery. When an outbreak of illness occurs, certain measures must be taken to prevent its spread.

 Cultures are done on all infected infants as well as on those who may be incubating the disease or may be asymptomatic carriers. ISOLATION ANTIBIOTIC THERAPY side effects

MATERNAL TRANSMISSION OF INFECTION TO THE NEONATE Treat the young infant for local infections There are three types of local infections in a young infant that a mother or caretaker can treat at home: an umbilicus that is red or draining pus skin pustules, and thrush. Follow the instructions in the TREAT THE YOUNG INFANT AND COUNSEL THE MOTHER section of the YOUNG INFANT chart.

Twice each day, the mother cleans the infected area and then applies gentian violet. Teach the mother how to treat the infection and check her understanding.

If the mother will treat thrush, give her a bottle of half-strength (0.25%) gentian violet. If the mother will treat skin pustules or umbilical infection, give her a bottle of full strength (0.5%) gentian violet.

MANAGEMENT OF HYPERBILIRUBINEMIA The aim of therapy is to ensure that serum bilirubin is kept at a safe level and brain damage is prevented. Exchange blood transfusion remains the single most effective and reliable method to lower the bilirubin when it approaches critical levels. However, other supportive and therapeutic measures are useful to prevent excessive rise of serum bilirubin and reduce the need for exchange transfusion.

Adequate feeding: Hydration should be maintained and hypoglycemia prevented by early feeding when jaundice is anticipated or already existent

Treatment of sepsis and hepatitis: When sepsis is suspected, appropriate antibiotics should be administered after collection of blood sample for culture. Vitamin K should be used with caution.

Phenobarbitone: Phenobarbitone in a single dose of 10 mg/kg intramuscular or 5 mg/kg/day in 2 divided doses orally for 3 days is indicated in

cases of cord serum bilirubin level of > 2.5 mg/dl.

Clofibrate: Clofibrate is a more potent enhancer than Phenobarbital. In one study, it caused a

100% increase in hepatic bilirubin clearance

within one week.

Phototherapy
Phototherapy is widely accepted as a relatively safe and effective method for treatment of neonatal hyperbilirubinemia. absorbs light maximally at 420-460 nm and light sources

whose peak emissions are in this range lower

serum bilirubin levels by several mechanisms. Phototherapy causes photo-oxidation of bilirubin into water soluble colorless form of bilirubin.

EXCHANGE BLOOD TRANSFUSION

Early indications for exchange blood transfusion in infants with Rhhemolytic disease of the newborn 1. 2. 3. Cord hemoglobin of 10 g/dl or less. Cord bilirubin of 5 mg/dl or more. Unconjugated serum bilirubin of 10 mg/dl within 24 hours or 15

mg/dl within 48 hours or rate of rise of > 0.5 mg/dl per hour.

Table : Maternal transmission of infection to the neonate

Infection Maternal infection Mother may have aids or is at risk for AIDS Clinical manifestation Small size prematurity failure to thrive respiratory disease Laboratory Diagnosis HIV titer (usually not detected before 4 no) Nursing intervention and management Prevention

Acquired immune deficiency syndrome (AIDS) Causative Agent (HIV) Time of transmission Tansplacental During pregnancy Contact with blood and secretion at delivery may be transmitted through breast feeding

Prevention Early HIV infection of increases the risk of pregnancy rapid progression to in AIDS. seropositive Zidovudine (Retrovir) mother prophylaxis is recommended for most infants exposed to HIV in utero to decrease the risk of vertical transmission. Beginning eight hours after birth, these neonates should receive zidovudine in a dosage of 2 mg per kg every six hours for at least six weeks.

Infection

Maternal infection

Clinical manifestation

Laboratory Diagnosis

Nursing intervention and management

Prevention

Cytomegalic inclusion disease (salivary gland virus) causative agent Cytomegalvirus Time of Transmission Transplacental throughout pregnancy and during delivery Fetal damage most severe if infection occurs in ist trimester

Half of childbearing women have no immunologic response to this virus mother asymptomati c this disease is most common cause of intrauterine infection

Premature delivery lethargy jaundice hemolytic anemia thrombocytop enia pneumonitis hepatospleno megaly

Isolate virus from nasopharyn x blood and urine \elevated IgM in neonate

No specific treatment available transfusions for anemia antimicrobial agents for concurrent bacterial infections

None experiment al live CMV vaccines are being evaluated

Infection

Maternal infection

Coxsackie Nonspecific Causative agent illness in Coxsackievirus mother Time of transmission Transplacental during delivery or in the neonatal period

Nursing intervention and management Condition Viral Supportive care common but antibody isolation of affected clinical studies on neonate manifestations acute and No effective antiviral relatively rare convalescen chemotherapy Elevation of t sera temperature examination respiratory of feces and collected for gastrointestina virus l symptoms isolation lethargy and feeding difficulties petechiae apneic period cyanosis jaundice,.

Clinical manifestation

Laboratory Diagnosis

Prevention

Gamma globlin is not effective in prevention prevent cross infection and epidemics in nursery with isolation technique

Infection

Maternal infection Maternal herpetic vulovagintis usually evident (HSV II)

Herpes simples (HSV I) causes common cold sore or fever blister HSV II causes cervicitis and vaginits Sexually transmitted Causative Agent Herpesvirus hominis \Time of transmission Transplacental or transmniotic at delivery

Nursing Prevention intervention and management Mild with few Isolation of Supportive treatment Less risk if skin lesions virus from of dehydration delivered (vesicles) or lesions by severe serologic cesarean systemic tests show section. disease rise in level active hypothermia of gential or fever neutralizing herpes anemia antibody lesions hepatitis during Acyclovir a jaundice convalescen treatment hepatomegaly ce should be thrombocytop given enia during pregnancy only if the potential benefit justifies the potential risk to the fetus

Clinical manifestation

Laboratory Diagnosis

Infection

Maternal infection Mother may be asymptom atic or have active or chronic infection

Infectious hepatitis Causative agent Infections with hepatitis B can be identified Time of transmission Any time during gestation or delivery or during neonatal period from cracked nipples or breast milk

Clinical manifestati on Prematurity may be asymptomati c of have jaundice hepatosplen omegaly hemolytic anemia

Laborator y Diagnosis Liver function test indictes obstructive type of jaundice

Nursing intervention and management No effective antiviral chemotherapeutic agent medical isolation with emphasis on handwashing use of gloves when handling infant drawing blood or caring for excretions

Preventio n Hepatitis B immune gamma globulin or standard immune serum globulin should be given to neonates of mother having clinical hepatitis B near time of delivery

Infection

Maternal infection Infection of cervix and vagina Infection of cervix and vagina : otherwise asymptomati c Most common cause of ophthalmitis in neonates

Clinical manifestation Conjuctivitis Mild to severe conjunctivitis : purulent discharge from one or both eyes swollen lids pseudomembr anes possibly distinctive syndrome of pneumonia (tachypnea cough vomiting cyanosis)

Laboratory Diagnosis Gram stain and culture (Thayer Martin medium of purulent exudates from eye Culture or Giemsa stain of conjuctival scraping bacterial cultures negative

Nursing intervention and management Strict isolation use of arm restraints to prevent rubbing of eye (s) An eye shield may be used for protection over unaffected eye intravenous or intramuscular aqueous penicillin G Warm saline irrigations of eye instillation of penicillin G tetracycline or chlorampheniocol eye drops Conjunctivitis : tetracycline or sulfonamides.

Prevention

Ophthalmitis (ophthalmia neonatorum) 1. Gonococcal Causative Agent Neisseria gonorrhoeae time of transmission during delivery 2. Chalmydial Causative Agent : Chlamydia trachomatis time of transmission during delivery

Prevention treatment of maternal disease instillation after birth of 1% solution of silver nitrate or erythromyci n or tetracycline ophthalmic ointment

Clinical manifestati on Rubella Mild Low birth (German usually. weight measles ) Mother Anemia, Causative may have rash, agent encephaliti thrombocyto Rubella virus s penic Time of purpura, transmission jaundice, Transplacental hepatitis, :first trimester hepatosplen If mother omegaly, contracts osteitis, rubella in 1st myocarditis, months of pneumonia, gestation chronic incidence of meningoenc malformation is ephalitis, 30 to 505

Infection

Maternal infection

Laborator y Diagnosis Viremia isolate virus from nasophary nx, urine,

Nursing intervention and management Strict isolation for as long as virus is present in urine or pharynx; this may continued for many months

Preventio n Active immunizat ion should be done if women are not immune prior to but not during gestation Susceptibl e pregnant women should avoid contact

Infection

Maternal
infection

Clinical
manifestation

Laboratory
Diagnosis

Nursing
intervention and management

Prevention

Rubeola (measles) causative agent : Measles virus time of transmission : tansplacental : 1st trimester or any time during

Mild usually

Low birth weight Congenital or neonatal measles; skin lesions like those of mother , diarrhea

Isolation of virus from blood, urine, nasopharyn x Antibody titer

Supportive care

Vaccination before pregnancy Use of live measles vaccine is not recommend ed during

gestation

pregnancy

Infection

Maternal infection
Fetus is affected if untreated maternal infection occurs less than 1 to 2 yr before gestation.

Clinical manifestation
Premature delivery Early congenital syphilis: maculopapular rash; moist mucocutaneous lesions (syphilitic pemphigus on palms and soles)

Laboratory Diagnosis
Dark-field examination for spirochetes, especially of cerebrospinal fluid

Nursing intervention and management

Intravenous or intramuscular penicillin during neonatal period After the neonatal period, erythromycin and tetracycline may be used for children allergic to penicillin nurse wear disposable gloves to prevent contamination of open lesions on hands . If photophobia is present in older child, darken the room or provide dark glasses.

Prevention

Syphills Causative Agent: Treponemapallidu m Time of Transmission: Transplacental and hematogenous, any time during pregnancy

Serologic blood test before marriage Routine serologic testing of pregnant women in 1st and 3rd trimesters

Infection

Maternal infection

Clinical manifestation

Laboratory Diagnosis

Nursing intervention and management

Prevention

Thrush (oral monillasis Causative Agent: Candida albicans (fungus) Time of Transmission: During birth from a contaminated birth canal: after delivery from contact with infected infants and contaminated supplies or caregivers May occur when antibiotic therapy changes oral flora

Vaginal monillasis

White plaques (resembling milk curds) over tongue, lips, gingival and buccal mucous membranes. When removed, they leave a bright red., bleeding base Anorexia may be due to discomfort from lesions Esophagogastrit is or pneumonitis may develop

Direct microscopic examination and culture of scraping from oral cavity

Nystain solution or 1% aqueous gentian violet applied slowly and gently to individual lesions several times each day. placed prone so that saliva will drain from the mouth and the infant will not swallow the remainder of the drug. If gentaian violet stains the clothing or bed lines, the stains can be removed with sodium bicarbonate paste

Treatment of maternal infection Thorough handwashin g and cleanliness of supplies Inspect mouth of infants receiving antibiotic theraphy

Infection

Maternal infection Transmitted to mother by ingestion of infected raw meat or unwashed raw fruits or vegetables raised at soil level, or by handling of cat feces Maternal infection many times is asympomatic

Clinical manifestation Premature delivery Some neonates may not be infected; other may have anemia, jaundice, hepatosplenome galy, encephalitis, convulsions, chorioretinitis

Laboratory Diagnosis Higher titer of dye test antibody, but no complementfixing antibody Abnormal cerebrospinal fluid containing parasites

Toxoplasmosis Causative Agent: Toxoplasma gondil Time of Transmission: In utero: 1st trimester, but any time during pregnancy. Since the organism crosses the placenta during an acute infectio, only 1 infant/family can acquire this disease

Nursing intervention and management Combination of sulfadiazine and pyrimethamine (Daraprim). (Frequent leukocyte counts must be done because both drugs cause leucopenia) Supportive care

Prevention

Maternal antibody titer done before pregnancy Prevent maternal exposure; Hands should be washed after handing raw meat, and fruits and vegetables should be washed carefully

NEONATAL INFECTON NEONATAL INFECTONS ACQUIRED AFTER BIRTH

INFECTION

Impetigo contagiosa. Causative Agent: Streptococcus, Staphylococcus

SOURCE OF Infection/La boratory Diagnosis Direct contact with contaminated hands of caregivers or with contaminated supplies Laboratory: Culture lesions

Clinical Manifestation s

Nursing Intervention and Managemen t Invasion of Crusts are superficial removed layers of skin carefully after : at first softening with erythematous 1:20 Burrows macules; later, solution vesicles compresses When vesicles Application of break, they Neo-Polycin, leave superficial Neosporin moist areas ointment Amber-colored If infection is crusts form extensive, a when exudates systemic dries antibiotic Highly (penicillin) is contagious administered orally or parentrally

Outcome

Prevention

Heals without scarring unless lesions become secondarily infected Can be spread to self and other through contact

Skin cleanliness Prevention of contact with infected lesions

INFECTION

SOURCE OF Clinical Infection/Lab Manifestations oratory Diagnosis Inadequate care of umbilicus; contamination with soiled diaper or with hands of caregivers Laboratory; Culture umbilical stump Redness, moisture or purulent discharge, and induration of card stump Foul odor cord stump Possible septicemia

Nursing Intervention and Management

Outcome

Prevention

Omphalities Causative Agent: Escherichia coli, Staphylococci, Other pyogenic organisms

Careful Good with early cleansing of recognition and the umbilicus adequate treatment with antiseptic solution, such as alcohol or triple dye Local application and systemic use of broadspecturm antibiotic If abscess forms, incision and drainage may become necessary

Assessment and cleaning of umbilicus until healed

BIBLIOGRAPHYDorothy R Marlow. Barbara A. Redding.Textbook of Peadiatric Nursing .6th Edition. New Delhi, Saurabh publications; 2006.Page no- 450-630. Basvanthappa BT.Textbook of Pediatric Child Health Nursing.1st Edition.New delhi . Ahuja Publications House;2008.Page no-114-122. Singh Meherban.Textbook of Care of Newborn.6th Edition. NewDelhi.Sagar Publications;2002.Page no-261-390