What intrauterine factors affect fetal growth?
- Maternal factors: poor wt. gain in 3rd trimester, poor nutrition, preeclampsia, maternal prescription or illicit drug use, maternal infections, uterine abnormalities, maternal asthma.
- Placental abnormalities: placenta previa, placental abruptions or abnormal umbilical vessel insertions may lead to suboptimal fetal growth.
- Fetal abnormalities: Fetal malformations (eg renal dysplasia or a diaphragmatic hernia), metabolic disease, chromosomal abnormalities (such as trisomy 13), and congenital infections
- Multiple gestation
Effects of Alcohol (ethanol) on developing fetus:
- Increases risk of fetal alcohol syndrome: Facial abnormalities, growth deficiencies, CNS dysfunction (mental retardation, poor motor skills and hand-eye coordination, difficulties with memory, attention and judgement)
- There is no “safe” amount of alcohol that can be consumed during pregnancy to ensure that fetal alcohol syndrome does not occur.
Effects of Tobacco on developing fetus:
Increases risk for low birth weight. No characteristic facies.
Effects of Marijuana on developing fetus:
Distinctive effects of THC have not been identified, but infants born to mothers who smoke marijuana more than 6 times per week often have a withdrawal-like syndrome (high-pitched cry and tremulousness) in the first days after birth.
Effects of Cocaine and other stimulants on developing fetus:
- Vasoconstriction, leading to placental insufficiency and low birth weight
- May lead to subtle yet significant later deficits in cognitive performance, including information processing, and attention to tasks
Babies born to mothers who have HIV have what chance of HIV infection?
About a 25-30 percent chance.
What do some states mandate offering to women during pregnancy?
What events increase the risk of vertical (mother-to-fetus) HIV transmission?
Freq., unprotected sex during pregnancy, Amniocentesis, Advanced maternal HIV disease, Breastfeeding, Premature delivery (before 37 weeks). In the era before anti-retrovirals were used during pregnancy: 1. Membrane rupture greater than 4 hrs prior to delivery 2. Vaginal delivery
What has been shown to decrease the risk of vertical HIV transmission?
- Zidovudine (anti-retroviral drug)
- Caesarean delivery if prior to onset of labor and membrane rupture
- No breastfeeding
What is metabolic screening?
Looks for inborn errors of metabolism. Other metabolic conditions have a more insidious onset. The newborn screen helps test for conditions that might not be readily picked up.
What can inborn errors of metabolism present with in neonates?
Anorexia, lethargy, vomiting and seizures.
What metabolic conditions do all states screen for?
Phenylketonuria (PKU) and hypothyroidism.
What metabolic conditions do some states screen for?
Galactosemia, biotinidase deficiency, hemoglobinopathy, maple syrup urine disease (MSUD), homocystinuria, congenital adrenal hyperplasia, CF, G6PD deficiency, and toxoplasmosis. Many states now screen for more than 30 diseases using tandem mass spectrometry.
All newborns are screened for congenital deafness.
Critical congenital heart defects screening:
Guidelines published in 2011 recommended the implementation of screening newborns for significant congenital heart defects. Screening would consist of the measurement of oxygen saturation.
What are the benefits of breast feeding?
Human milk is recognized by the AAP as the optimal food for infants. (Breast milk plus fortifier is recommended for premature babies).
- BM stimulates GI growth and motility.
- Dec risk of acute illness during time infant is fed breast milk
- Lower rates of diarrhea, acute and recurrent otits media and urinary tract infections
- Small neurodevelopmental advantages, including cognitive and motor development
What are the absolute contraindications to breastfeeding?
Rare and may include maternal HIV infection, active maternal drug abuse and infants with galactosemia.
When is exclusive breast feeding recommended?
For the first 6 months of live, and then breastfeeding plus complementary foods until the infant is at least 12 months of age.
There are associations between the duration of breast feeding and a reduction in what?
Incidence of obesity, cancer, adult coronary artery disease, certain allergic conditions, type 1 DM and inflammatory bowel disease.
What are the potential maternal benefits of breast feeding?
Decreased risk of breast and ovarian cancer and osteoporosis.
How often should mothers nurse their babies?
Whenever there are signs of hunger, which often is 8-12 times per day.
What should be done prior to discharge with breast feeding?
Evaluate mother and baby for adequacy of latch-on, suckling and milk transfer and progress of lactogenesis (milk production). Provide mothers with education, resources and follow up before discharge.
What should be assessed 24-48 hours after discharge?
An in-home lactation specialist or physician should assess adequate urine or stool output as well as weight change.
What are the 3 leadings causes of death for adolescents in the US?
Accidents, homicide and suicide.
What is the HEEADSSS interview for adolescents?
Home, Education/Employment, Eating disorder screening, Activities/Affiliations/Aspirations, Drugs (and alcohol, tobacco and steroids), Sexuality, Suicidal behavior (along with depression and mental health) and Safety (abuse, fights, weapons, seatbelts, etc)
What is important to remember about infants of adolescent mothers?
- Greater risk for lower brith weight, partly due to increased risk of pregnancy-induced HTN and preeclampsia and vertically acquired sexually transmitted diseases.
- Infants born to adolescents also have poorer developmental outcomes
What other factors increase the risk of neonatal problems?
- Poor or nonexistent prenatal care
- Maternal illness (mental and physical)
- Maternal high-risk behaviors (illicit drug use, unprotected sex)
- Family history of congenital/genetic disorders
- Poor nutrition
- Premature delivery
In addition to remembering the ABCs , keep in mind some of the special features of routine newborn resuscitation:
- Infants have large surface area relative to their body weight and therefore can experience significant hypothermia from evaporation.
- Warm and dry infant immediately.
- Remove any wet linens.
- Stimulate infant to assist in a vigorous ry, which helps to clear the lungs and mobilize secretions
- Suction amniotic fluid from infant’s nose and mouth to help clear to upper airway.
Some newborn infants require further resuscitation, such as:
- Blow-by oxygen
- Positive pressure (bag-valve mask) ventilation with oxygen
- Chest compressions
What are the five components of the APGAR score?
Appearance, Pulse (HR), Grimace (facial expression), Activity (neuromuscular tone), Respirations (respiratory effort)
Assesses neuromuscular and physical maturity. Method is helpful if there is no early prenatal US to help confirm dates or if gestational age is in question bc of uncertain maternal dates.
What is small for gestational age (SGA)?
Less than 10th percentile on the intrauterine growth curve.
What clinical problems are associated with SGA?
- Hypoglycemia (due to decreased glycogen stores, decreased gluconeogenesis). Sx include poor feeding and listlessness, but also commonly asymptomatic.
- Hypothermia (due to cold stress, decreased subcutaneous insulation). Sx include poor feeding and listlessness, but also commonly asymptomatic.
- Polycythemia (due to hypoxia or maternal-fetal transfusion; sx include a “ruddy” or red color to skin, respiratory distress, poor feeding and/or hypoglycemia)
What should be monitored closely in an SGA infant?
Temperature and blood glucose
What is appropriate for gestational age (AGA)?
Within 10-90th percentile on the intrauterine growth curve.
What’s large for gestational age (LGA)?
Greater than 90th percentile on the intrauterine growth curve.
What are clinical problems association with LGA?
C section delivery, delivery by forceps or vacuum (increased risk for cephalohematoma); birth injuries (clavicle fracture, brachial plexus injury, facial nerve palsy) and hypoglycemia.
What is microcephaly?
Head circumference less than 10th percentile for gestational age.
What should you do when examining the hips of an infant?
Ortolani and Barlow examinations should demonstrate no instability of the hips, and no “clicks” or “clunks” heard or palpated.
What are the TORCH infections?
Toxoplasmosis, Other - HIV, hep B, human parvovirus and syphillis, Rubella, CMV and Herpes virus type 2
What can a congenital TORCH infection cause?
Microcephaly, organomegaly and rash.
More than how many newborns with congenital CMV infection have no clinical evidence of disease?
More than 90 percent.
What are the symptoms of congenital CMV infection?
Skin, CNS and hepatobilliary system. Jaundice, chorioretinitis, hearing loss, intracranial calcifications.
What can chromosomal abnormalities result in?
May result in infants who are SGA.
What studies are useful in evaluating a newborn with possible congenital cytomegalovirus?
Urine cytomegalovirus (CMV), Newborn hearing test, CT scan of head and ophthalmologic examination.
Urine cytomegalovirus (CMV):
A urine culture positive for CMV in the first three weeks of life is evidence of congenital CMV infection.
Newborn hearing test in CMV:
May be normal in a newborn. Hearing loss may progress over time.
CT scan of head in CMV:
Abnormalities of congenital CMV may include microcephaly, intracranial calcifications, enlarged ventricles, and abnormal gyri and a thickened cortex (a condition known as lissencephaly and agyria-pachygyria)
Ophthalmologic examination in CMV:
Review for evidence of chorioretinitis
Rapid HIV antibody test:
Negative result allows mother to proceed with breastfeeding.
Hepatitis B surface antigen (HBsAg):
HBsAg is necessary to determine if a newborn is at risk for hepatitis B infection. (Presence or absence of maternal hepatitis B core antibody does not predict risk for verticalhepatitisB transmission.)
Positive result is evidence of protection against the virus (with through past infection or immunization).
Monitoring the sequelae of CMV infection:
- Hearing loss is common in infants who have congenital CMV infection. In many infected infants onset of hearing loss may be after the newborn period (i.e., newborn hearing screen may be normal). An infant infected with CMV may develop hearing loss and progress to severe-to-profound bilateral hearing loss during the first year of life.
- Microcephaly and intracranial calcifications are factors associated with increased risk of CNS sequelae of congenital CMV infection. Ongoing developmental assessment is needed to observe for possible mental retardation and/or cerebral palsy.
- Regular ophthalmologic examinations to monitor for chorioretinitis.
- Hepatosplenomegaly and rash, the non-neurological neonatal clinical abnormalities of CMV infection, can be expected to resolve spontaneously within weeks
- Antiviral tx for CMV is indicated only for immunocompromised hosts.
What are routine medications given to newborns in US?
Vitamin K, Topical ophthalmologic antibiotic, Hep B vaccine, Hep B immunoglobulin (HBIG)
Why is Vitamin K given?
IM injection. Prevents hemorrhagic disease of the newborn (vitamin-k deficiency bleeding).
Why is topical ophthalmologic antibiotic given?
Either erythromycin, tetracycline or silver nitrate. Decreases risk of transmission of gonococcal conjunctivitis. (Neonatal prophylaxis does little to prevent conjunctivitis from chlamydia, which typically occurs 7-14 days after birth)
Why is hep B vaccine given?
CDC recommends hospitals administer the hep B vaccine to all newborns greater than 2000 grams, regardless of maternal testing results.
Why is hep B immunoglobulin (HBIG) given?
Given to infants at risk for vertical transmission (newborns whose mothers test positive for HbSAg).