Overview Of Neonates Free Essay Example

Brief Overview Of Neonates

A neonate (from Latin, neonatus) is a baby who is 4 weeks old or younger also called a new born. The term applies to premature, mature and postmature infants. The neonatal period is the first 4 weeks of a child’s life and it is a time when changes are very rapid. During these first 4 weeks of life,the child is at highest risk of dying. It is therefore crucial that appropriate feeding and care are provided during this period, both to improve the child’s chances of survival and to lay foundations for a healthy life.

Many critical events can occur in this period:

• Feeding patterns are established.
• Bonding between parents and infant begin.
• The risks for infections that may become more serious are higher.
• Many birth or congenital defects are first noted.

After the first hour of life, newborns should receive eye care, vitamin K, and recommended immunizations (birth dose of OPV and Hepatitis B vaccine). They should be assessed for birth weight, gestational age, congenital defects and signs of newborn illness.

Special care should be provided for sick newborns, those who are preterm and/or low birth weight, and those who are exposed or infected by HIV or have congenital syphilis.

Apgar scoring

The Apgar score helps find breathing problems and other health issues. It is part of the special attention given to a baby in the first few minutes after birth. The baby is checked at 1 minute and 5 minutes after birth for heart and respiratory rates, muscle tone, reflexes, and color.

A baby who needs help with any of these issues is getting constant attention during those first 5 to 10 minutes. In this case, the actual Apgar score is given after the immediate issues have been taken care of.

Each area can have a score of 0, 1, or 2, with 10 points as the maximum. Most babies score 8 or 9, with 1 or 2 points taken off for blue hands and feet because of immature circulation. If a baby has a difficult time during delivery and needs extra help after birth, this will be shown in a lower Apgar score. Apgar scores of 6 or less usually mean a baby needed immediate attention and care.

Sign Score = 0 Score = 1 Score = 2

• Heart rate Absent Below 100 per minute Above 100 per minute
• Breathing effort Absent Weak, irregular, or gasping Good, crying
• Muscle tone Flaccid Some flexing of arms and legs Well-flexed, or active movements of arms and legs
• Reflex or irritability No response Grimace or weak cry Good cry
• Color Blue all over, or pale Body pink, hands and feet blue Pink all over

Birth weight

A baby’s birth weight is an important marker of health. Full-term babies are born between 37 and 41 weeks of pregnancy. The average weight for full-term babies is about 7 pounds (3.2 kg). In general, very small babies and very large babies are at greater risk for problems. Babies are weighed every day in the nursery to look at growth, and the baby’s need for fluids and nutrition. Newborn babies may often lose 5% to 7% of their birth weight. This means that a baby weighing 7 pounds 3 ounces at birth might lose as much as 8 ounces in the first few days. Babies will usually gain this weight back within the first 2 weeks after birth. Premature and sick babies may not begin to gain weight right away.

Measurements

The hospital staff takes other measurements of each baby. These include:

• Head circumference. The distance around the baby’s head.
• Abdominal circumference. The distance around the belly (abdomen).
• Length. The measurement from top of head to the heel.

The staff also checks these vital signs:

• Temperature. This checks that the baby is able to have a stable body temperature in normal room.
• Pulse. A newborn’s pulse is normally 120 to 160 beats per minute.
• Breathing rate. A newborn’s breathing rate is normally 40 to 60 breaths per minute.

Physical exam

A complete physical exam is an important part of newborn care. The healthcare provider carefully checks each body system for health and normal function. The provider also looks for any signs of illness or birth defects. Physical exam of a newborn often includes:

• General appearance. This looks at physical activity, muscle tone, posture, and level of consciousness.
• Skin. This looks at skin color, texture, nails, and any rashes.
• Head and neck. This looks at the shape of head, the soft spots (fontanelles) on the baby’s skull, and the bones across the upper chest (clavicles).
• Face. This looks at the eyes, ears, nose, and cheeks.
• Mouth. This looks at the roof of the mouth (palate), tongue, and throat.
• Lungs. This looks at the sounds the baby makes when he or she breathes. This also looks at the breathing pattern.
• Heart sounds and pulses in the groin (femoral)
• Abdomen. This looks for any masses or hernias.
• Genitals and anus. This checks that the baby has open passages for urine and stool.
• Arms and legs. This checks the baby’s movement and development.

Gestational assessment

The healthcare provider will check how mature the baby is. This is an important part of care. This check helps figure out the best care for the baby if the dates of a pregnancy are uncertain. For example, a very small baby may actually be more mature than he or she appears by size, and may need different care than a premature baby needs.

Healthcare providers often use an exam called the Dubowitz/Ballard Examination for Gestational Age. This exam can closely estimate a baby’s gestational age. The exam looks at a baby’s skin and other physical features, plus the baby’s movement and reflexes. The physical maturity part of the exam is done in the first 2 hours of birth. The movement and reflexes part of the exam is done within 24 hours after birth. The provider often uses the information from this exam to help with other maturity estimates.

Physical maturity

The physical maturity part of the Dubowitz/Ballard exam looks at physical features that look different at different stages of a baby’s gestational age. Babies who are physically mature usually have higher scores than premature babies.

Points are given for each area of assessment. A low of -1 or -2 means that the baby is very immature. A score of 4 or 5 means that the baby is very mature (postmature). These are the areas looked at:

• Skin textures. Is the skin sticky, smooth, or peeling?
• Soft, downy hair on the baby’s body (lanugo). This hair is not found on immature babies. It shows up on a mature infant, but goes away for a postmature infant.
• Plantar creases. These are creases on the soles of the feet. They can be absent or range up to covering the entire foot.
• Breast. The provider looks at the thickness and size of breast tissue and the darker ring around each nipple (areola).
• Eyes and ears. The provider checks to see if the eyes are fused or open. He or she also checks the amount of cartilage and stiffness of the ears.
• Genitals, male. The provider checks for the testes and how the scrotum looks. It may be smooth or wrinkled.
• Genitals, female. The provider checks the size of the clitoris and the labia and how they look.

Maturity of nerves and muscles

The healthcare provider does 6 checks of the baby’s nerves and muscles.

A score is given to each area looked at. Typically, the more mature the baby is, the higher the score. These are the areas checked:

• Posture. This looks at how the baby holds his or her arms and legs.
• Square window. This looks at how far the baby’s hands can be flexed toward the wrist.
• Arm recoil. This looks at how much the baby’s arms “spring back” to a flexed position.
• Popliteal angle. This looks at how far the baby’s knees extend.
• Scarf sign. This looks at how far the baby’s elbows can be moved across the baby’s chest.
• Heel to ear. This looks at how near the baby’s feet can be moved to the ears.

When the physical assessment score and the nerves and muscles score are added together, the healthcare provider can estimate the baby’s gestational age. Scores range from very low for immature babies to very high scores for mature and postmature babies.

The normal fetus is sterile until shortly before birth, as long as the amniotic membrane remains intact. After birth, the neonate rapidly acquires commensal bacteria that colonise the skin and mucous membranes. The host defence mechanisms are not well developed at this stage and some commensals may become opportunist pathogens, particularly in compromised neonates who must remain in hospital for the treatment of congenital abnormalities. The gastrointestinal ‘tract is colonised soon after birth, mainly by facultative bacteria. Studies have shown that anaerobes colonise the neonatal gastrointestinal tract during the first week of life and are greater in number and variety than aerobes or facultative species. Subsequently, only micro-organisms that can adapt to live in this mixed population of facultative and anaerobic species will colonise the various parts of the tract and become part of the resident flora.

NEONATAL BACTERIAL INFECTIONS

NEONATAL INFECTION

Most infections in newborn babies are caused by bacteria, and some by viruses. A mother’s birth canal contains bacteria, especially if they have an active infection. During childbirth, the baby can swallow or breathe in the fluid in the birth canal, and bacteria or viruses can get into their lungs and blood. The baby can become sick during childbirth or within the first few days after birth. As the bacteria or viruses multiply, the newborn baby can become ill very quickly. The sooner the infection is discovered and treated, the better the outcomes will be for the newborn baby.

Infections are a major cause of neonatal mortality, responsible for approximately one third of the total neonatal deaths worldwide. Timely recognition of illness in sick neonates, appropriate care seeking and access to appropriate treatment is needed to reduce the neonatal mortality.

There are a number of bacteria and viruses that can be transmitted from mother to newborn baby during pregnancy or childbirth.

Neonatal infection can be acquired

• In utero transplacentally or through ruptured membranes
• In the birth canal during delivery (intrapartum)
• From external sources after birth (postpartum)

Common viral agents include herpes simplex viruses, HIV, CMV, and hepatitis B. Intrapartum infection with HIV or hepatitis B occurs from passage through an infected birth canal or by ascending infection if delivery is delayed after rupture of membranes; these viruses can less commonly be transmitted transplacentally. CMV is commonly transmitted transplacentally.

Bacterial agents include group B streptococci, enteric gram-negative organisms (primarily Escherichia coli), Listeria monocytogenes, gonococci, and chlamydiae.

In utero infection

In utero infection, which can occur any time before birth, results from overt or subclinical maternal infection. Consequences depend on the agent and timing of infection in gestation and include spontaneous abortion, intrauterine growth restriction, premature birth, stillbirth, congenital malformation (eg, rubella), and symptomatic (e.g., cytomegalovirus [CMV], toxoplasmosis, syphilis) or asymptomatic (e.g., CMV) neonatal infection.

Common infectious agents transmitted transplacentally include rubella, toxoplasma, CMV, and syphilis. HIV and hepatitis B are less commonly transmitted transplacentally.

Intrapartum infection

Neonatal infections with herpes simplex viruses, HIV, hepatitis B, group B streptococci, enteric gram-negative organisms (primarily Escherichia coli), Listeria monocytogenes, gonococci, and chlamydiae usually occur from passage through an infected birth canal. Sometimes ascending infection can occur if delivery is delayed after rupture of membranes.

Postpartum infection

Postpartum infections are acquired from contact with an infected mother directly (e.g., TB, which also is sometimes transmitted in utero) or through breastfeeding (e.g., HIV, CMV) or from contact with family or visitors, health care practitioners, or the hospital environment.

Symptoms of infection

The symptoms of a beginning infection are listed below. Determining if a new born has an infection may be difficult because healthy newborn babies can also have some of these symptoms even though there is no infection. In a newborn baby with an infection, these symptoms will continue and the baby needs to be checked by a doctor.

• irregular temperature below 36.6 degrees C (97.9 degrees F) or above 38.0 degrees C (100.4 degrees F), taken rectally
• poor feeding and difficulty waking to feed
• excessive sleepiness
• irritability
• rapid breathing at a rate over 60 breaths per minute
• change in behaviour

As the infection gets worse, the newborn baby may develop additional symptoms:

• difficulty breathing
• bluish tinge around mouth
• pale or grayish skin
• high body temperature (above 38.0 degrees C or 100.4 degrees F, taken rectally)
• low body temperature (under 36.6 degrees C or 97.9 degrees F, taken rectally), despite being wrapped with clothes and blankets

Diagnosis of infection

Several tests can be used to diagnose the infection. However, test results usually take two to three days to come back, so in the meantime, the doctor will prescribe antibiotics for the newborn baby while they are waiting for the test results to confirm the diagnosis. For example, rapid breathing could be caused by infection, and any delay in treatment could result in the newborn baby becoming much more ill.

The following tests may be needed to diagnose infection in newborn babies:

• Complete blood count: This is when a sample of the newborn baby’s blood is taken. The complete blood count (CBC) will determine the number of each type of blood cell. Special attention is focused on the number of white blood cells (WBCs), as these can be abnormal in number when an infection is present. An abnormal number of WBCs often indicates that the newborn baby’s body is fighting some sort of infection. Results of the CBC can be obtained quite quickly.
• Blood culture: The blood culture will determine if any bacteria can be grown in the blood. If bacteria grow in the culture, the baby has an infection in the bloodstream. The results of this test can take up to 24 hours and sometimes longer, which is why treatment is not delayed while waiting for the result.
• Urine test: This is when a sample of the newborn baby’s urine is taken to determine its white cell count and sent away for culture.
• Eye or skin swab: This is when pus or fluid from a possible site of infection, such as the eye or umbilical cord, is swabbed and sent away for analysis.
• Chest X-ray: A baby needs a chest X-ray if pneumonia is suspected.
• Spinal tap: A lumbar puncture is also called a spinal tap, and it is necessary if an infection of the lining of the brain, called meningitis, is suspected. Before doing a lumbar puncture, a numbing cream may first be applied to the area of the spine where the lumbar puncture will take place. Local anaesthetic is then used to numb the site of the lumbar puncture. A hollow needle is inserted between the bones, called the vertebrae, of the spine. A sample of the cerebrospinal fluid is withdrawn through the needle and tested for infection. This is not a comfortable procedure; however, sedation and pain relief are provided to reduce the baby’s discomfort. Meningitis is a serious infection and the diagnosis can only be confirmed by examination of the cerebrospinal fluid.

Treatment of infections

• If the newborn baby has an infection, they may be taken to the special care nursery of the hospital, where they will be placed on a warming bed or in an incubator to regulate their body temperature. They may be attached to a cardiorespiratory monitor to measure their heart rate and breathing. They may also need a monitor called a pulse oximeter to determine if there are appropriate levels of oxygen in their body.
• If a bacterial infection is suspected, the newborn baby will be given antibiotics. As infections in the newborn baby can be very serious and require quick and effective antibiotic treatment, the antibiotics are given as an intravenous (IV) infusion. The IV is a hollow tube that sits in a vein. The IV ensures that the right amount of antibiotic enters your baby’s blood. Antibiotics are not given to newborn babies by mouth because they are not absorbed very well from the stomach. The baby’s doctor will monitor the amount of antibiotic in the baby’s bloodstream, to make sure that they are receiving the right dosage. The length of time that antibiotics are administered depends on the type of infection that is being treated. Treatment can range from seven to 21 days. If the test results are negative, the antibiotics will most likely be discontinued.
• Viral infections do not respond to antibiotics. Therefore, if it turns out that the newborn baby has a viral infection, they will usually need to fight the infection without medication. Supportive care, described below, will be given. Antiviral drugs are available to treat specific viruses such as herpes or HIV.
• In addition to antibiotics, the newborn baby may be given other supportive care. For example, they may need IV fluids to prevent dehydration, or if they are too sleepy to eat. They may also need a tube inserted into their nose or mouth to drip milk directly into their stomach. This is called a nasogastric or gavage tube. Some newborn babies need extra oxygen during this time, especially if they have pneumonia.

Consequences

The consequences of infection in the newborn vary according to the gestational age, site of the infection, and micro-organism(s) involved. In general, due to the immaturity of the immune system in extremely premature babies, they have the worst incidence of mortality and significant morbidity. The site of infection is an important consideration:

• Blood: Isolated septicaemia is the most common form of severe infection encountered in the NICU.
• CSF: Meningitis in premature babies is a devastating occurrence. Death occurs in about 50% of cases, and survivors are at risk of significant brain injury, with deafness and/or mental retardation.
• Pneumonia: Newborns with congenital pneumonia have high mortality. Infections are most commonly due to E coli. They have high ventilator requirements, and the course is commonly complicated by persistent fetal circulation. Blood cultures are positive in about 50% of cases. The mother has often received intrapartum antibiotics because of chorioamnionitis (also known as intra-amniotic infection (IAI) is an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection. It typically results from bacteria ascending from the vagina into the uterus and is most often associated with prolonged labor) and/or ruptured membranes. Acquired pneumonia may be bacterial, e.g. Pseudomonas, or viral, e.g. RSV.
• Bone: Osteomyelitis may have serious long-term sequelae, but fortunately it has become very rare since infection due to Staphylococcus aureus has become very uncommon in our nursery.

Neonatal infections account for a significant proportion of neonatal deaths in the first week of life. In sub-Saharan Africa, south Asia, and Latin America where neonatal infections are most prevalent, the case fatality risk associated with possible severe bacterial infections in the first month of life is 9.8%. Infections are one of the three major causes of neonatal mortality and account for approximately a quarter of newborn deaths in the first month of CHlife. Neonatal infections are acquired horizontally (from the environment) or vertically (from mother).