NCM 109

Care of Children
@
Risk/ High Risk

WILBERT ANTONINO CABANBAN,RN,MAN

Health Problems of the Newborn

A. Birth Injuries
Several factors predispose an infant to birth injuries.
Many injuries are minor and resolved spontaneously in a few days; others, although minor,
require some degree of intervention. Still others can be serious or even fatal.
Part of nurses responsibility is to identify such injuries so that appropriate interventions can be
initiated as soon as possible.
1. Soft Tissue Injury

 Infants may sustain various types of soft tissue injury during birth, primarily in the form of
bruises and abrasions secondary to dystocia. Soft tissue injury usually occurs when there is
some degree of disproportion between the presenting part and maternal pelvis.
 Erythema
1.a. Erythema & Abrasions
• Erythema is a superficial reddening of the
skin, usually in patches, as a result of
injury or irritation causing dilatation of
the blood capillaries.
• Abrasions is an area damaged by scraping
or wearing away.
• Usually the result of the application of
forceps; discoloration the same
configuration as the instrument. Abrasions
1.b. Petechiae
•Nonraised, pinpoint hemorrhages caused by
sudden increase and then release of pressure
during passage through the birth canal; may
be seen on the chest, face, and head.
•Caused by the breakage of capillaries.
•They may be seen on the face as a result of
pressure exerted on the head during birth.
1.c. Ecchymoses
•Small hemorrhagic areas (larger than
petechiae) that may occur after traumatic,
precipitous, or breech delivery.
•Associated with prolonged delivery.
•Ecchymosis is the medical term for the
common bruise. Most bruises form when
blood vessels near the surface of the skin are
damaged, usually by impact from an injury.
The force of the impact causes your blood
vessels to burst open and leak blood. This
blood gets trapped beneath the skin, where it
forms into a little pool that turns your skin
purple, black, or blue.
1.d. Subcutaneous fat Necrosis Evolution of Subcutaneous Fat
•Clearly outlined masses located in the Necrosis
subcutaneous tissues that are firm to the
overlying skin but movable over the
underlying tissue; most likely caused by
traumatic manipulation during delivery.
1.e. Subconjunctival (scleral)
Hemorrhages
•The result of rupture of capillaries in the
sclera from pressure on the fetal head during
delivery; most commonly located in the
limbus of the iris.
1.f. Retinal Hemorrhages
•Flame-shaped, irregular, or round areas of
bleeding in the retina from excessive pressure
on the fetal head during delivery; extensive
areas possibly indicative of subdural
hematoma or brain trauma.
Nursing Care Management
Nursing care is directed toward assessing the injury, maintaining asepsis care of the area to prevent additional skin
breakdown and infection, and providing an explanation and reassurance to the parents.
2. Head Injury
Head injury that occurs during the birth process is usually
benign but occasionally results in more serious injury.
2.a Caput Succedaneum
•The most commonly observed scalp lesion is
caput succedaneum, a vaguely outlined area
edematous tissue situated over the portion of
the scalp that presents in a vertex delivery.
The swelling consists of serum and/or blood
that has accumulated in the tissues above the
bone. Typically the swelling extends beyond
the bone margins (or sutures) and may be
associated with overlying petechiae or
ecchymosis.
•It is present at or shortly after birth. No
specific treatment is necessary, and the
swelling subsides within a few days.
 2.b Subgaleal Hemorrhage

Subgaleal hemorrhage or hematoma is bleeding

in the potential space between the skull
periosteum and the scalp galea aponeurosis.
SGH occurs in roughly 0.04% of spontaneous
vaginal deliveries and 0.59% of vacuum-
assisted deliveries.
Subgaleal hematomas have the potential to
drain a significant amount of blood from the
newborn, putting the baby at risk of injuries
including neonatal encephalopathy (brain
damage), seizures, or even death. The reported
mortality rate in infants with SGH is 22.8%
(2). Due to the high-risk nature of this
condition, it is crucial that SGH be identified
and treated promptly to avoid and/or limit
damage to the baby.
Treatment for a subgaleal hematoma is aimed at resolving the symptoms of
blood loss and assuring that the infant returns to a stable condition. This often
includes volume resuscitation and blood transfusions to correct ongoing
bleeding. During volume resuscitation, liquids are restored to the infant in the
form of packed red blood cells (to help restore the oxygen-carrying function of
blood), normal saline, and fresh frozen plasma.
2.c Cephalhematoma
Cephalohematoma is a traumatic
subperiosteal haematoma that occurs
underneath the skin, in the periosteum of the
infant's skull bone. Cephalohematoma does
not pose any risk to the brain cells, but it
causes unnecessary pooling of the blood from
damaged blood vessels between the skull and
inner layers of the skin.
Aspiration is not effective because the blood
has clotted. Also, entering
the cephalohematoma with a needle increases
the risk of infection and abscess formation.
The best treatment is to leave the area alone
and give the body time to reabsorb the
collected fluid.
3. Fracture
Fracture of the clavicle, or collar bone, is the most common birth
injury. It is often associated with difficult vertex of breech deliveries
of infants of greater-than-average size. Further examination usually
reveals crepitus radiographs usually reveal a complete fracture with
overriding of the fragments. A palpable spongy mass, representing
localized edema and hematoma, is also a sign of a fracture clavicle.
3.a. Fracture clavicle
The newborn with fractured clavicle may
have no symptoms, but the nurse should
suspect a fracture if an infant has limited use
of the affected arm, malpositioning of the
arm, asymmetric Moro Reflex or focal
swelling or tenderness or cries when the arm
is moved.
In neonates, fractures of long bones, such as
the femur or the humerus, are often difficult
to detect by radiographic examination.
Moro Reflex
The Moro Reflex is an infantile reflex that
develops between 28–32 weeks of gestation
and disappears between 3–6 months of age. It
is a response to a sudden loss of support and
involves three distinct components: spreading
out the arms (abduction) pulling the arms in
(adduction) crying (usually)
Nursing Care Management

Often no intervention is prescribed other than proper body alignment, careful

dressing and undressing of the infant, and handling and carrying techniques that
support the affected bone. If the infant has a fractured clavicle, it is important to
support the upper and lower back rather than pull the infant up from under the
arms. Occasionally for immobilization and relief of pain, the arm on the side of
the fractured clavicle may be abducted at more than 60 degrees with the elbow
flexed at more than 90 degrees for 7 to 10 days.
NURSING ALERT!

Any newborn who is large for gestational age or

weighs more than 4000g (8lb, 8 oz) and is
delivered vaginally should evaluated for a
fractured clavicle.

Note! The MD might suggest Cesarean Section

Delivery.
4. Nerve Injuries
4.a. Facial Paralysis
Pressure on the facial nerve during delivery
may result in injury to the nerve. The primary
clinical manifestations are loss of movement
on the affected side, such as an inability to
completely close the eyes, drooping of the
corner of the mouth, and absence of
wrinkling of the forehead and nasolabial fold.
The paralysis is more noticeable when the
infant cries. The mouth is drawn to the
unaffected side, the wrinkles are deeper on
the normal side, and the eye on the involved
side remains open.
A. Paralysis of right side of face 15 minutes after
No medical intervention is necessary. The forceps delivery. Absence of movement on
paralysis usually disappears spontaneously in affected side is especially noticeable when
a few days but may take long as several infant cries.
months.
B. Same infant after 24 hours.
4. b. Brachial Palsy/ Erb Palsy
Brachial plexus injury results from forces that
alter the normal position and relationship of the
arm, shoulder, and neck.
Erb Palsy (Erb-Duchenne Paralysis) is caused
by damage to the upper plexus and usually
results from stretching or pulling away of the
shoulder from the head, as might occur with
shoulder dystocia or with a difficult vertex or
breech delivery.
4.c. Phrenic Nerve Paralysis
Phrenic nerve palsy may result from birth
trauma during a traumatic neonatal delivery
from a stretch injury due to lateral
hyperextension of the neck at birth. This
could be a rare cause of respiratory distress in
the newborn period with irregular respiration.
5. Cranial Deformities

In normal newborn the cranial sutures are separated by membranous seams several
millimeters wide. For the first few hours to 1 to 2 days after birth, the cranial bones are
highly mobile, which allows the bones to mold and overlap one another, adjusting the
circumference of the head to accommodate to the changing shape and character of the
birth canal.
Normally, sutures and fontanels are ossified by the following ages;
8 Weeks – Posterior fontanel closed
6 months – Fibrous union of suture lines and interlocking of serrated edges
18 months – Anterior fontanel closed
12 years and older – Sutures not separable by ICP

Note! Closure of a suture before the expected time inhibits the perpendicular growth.
5.a Microcephaly
Microcephaly is a medical condition in which
the circumference of the head is smaller than
normal because the brain has not developed
properly or has stopped growing.
Microcephaly can be present at birth or it may
develop in the first few years of life.
Microcephaly
Two Types
1. Primary (Genetic) Microcephaly refers to a small head size that may be caused by an autosomal recessive or
autosomal dominant disorder or chromosomal abnormality such as Down Syndrome or Cornelia de Lange
syndrome.
2. Secondary (Non-genetic) Microcephaly can result from variety of insults that occur during the third trimester
of pregnancy, the perinatal period, or early infancy.
Secondary Microcephaly may also occur as a result of maternal diabetes and maternal hyperphenylalanemia.
What Causes Microcephaly?
It is most often caused by genetic abnormalities that interfere with the growth of the cerebral cortex during the early
months of fetal development. It is associated with Down's syndrome, chromosomal syndromes, and neurometabolic
syndromes. Babies may also be born with microcephaly if, during pregnancy, their mother abused drugs or alcohol,
became infected with a cytomegalovirus, rubella (German measles), or varicella (chicken pox) virus, was exposed to
certain toxic chemicals, or had untreated phenylketonuria (PKU).
Babies born with microcephaly will have a smaller than normal head that will fail to grow as they progress through
infancy.
Nursing Care Management

There is no specific treatment. Nursing care is supportive and may be directed

toward helping parents adjust to rearing a child with cognitive impairment
when this condition is present.
5.b Craniostenosis

Craniostenosis is a birth defect in which

one or more of the fibrous joints
between the bones of your baby's skull
(cranial sutures) close (fuse)
prematurely, before your baby's brain is
fully formed. Brain growth continues,
giving the head a misshapen appearance.
Normally, during infancy the sutures remain flexible, giving your baby's brain time to
grow. In the front of the skull, the sutures meet in the large soft spot (fontanel) on top of
the head. The anterior fontanel is the soft spot you feel just behind your baby's forehead.
The next largest is at the back (posterior). Each side of the skull has a tiny fontanel.

It usually involves premature fusion of a single cranial suture, but can involve more than
one of the sutures in your baby's skull. In rare cases, it is caused by certain genetic
syndromes (syndromic craniostenosis).
Types of Craniostenosis

1. Sagittal (scaphocephaly). Premature fusion of the sagittal suture that runs from the front to the back at the top
of the skull forces the head to grow long and narrow. Sagittal craniostenosis results in a head shape called
scaphocephaly and is the most common type of craniostenosis.
2. Coronal. Premature fusion of one of the coronal sutures (unicoronal) that run from each ear to the top of the
skull may cause the forehead to flatten on the affected side and bulge on the unaffected side. It also leads to
turning of the nose and a raised eye socket on the affected side. When both coronal sutures fuse prematurely
(bicoronal), the head has a short and wide appearance, often with the forehead tilted forward.
3. Metopic. The metopic suture runs from the top of the bridge of the nose up through the midline of the
forehead to the anterior fontanel and the sagittal suture. Premature fusion gives the forehead a triangular
appearance and widens the back part of the head. This is also called trigonocephaly.
4. Lambdoid. Lambdoid synostosis is a rare type of craniosynostosis that involves the lambdoid suture, which
runs along the back of the head. It may cause one side of your baby's head to appear flat, one ear to be higher
than the other ear and tilting of the top of the head to one side.
Treatment

Treating craniostenosis involves surgery (craniectomy) to correct the shape of the

head and allow for normal brain growth. Early diagnosis and treatment allow your
baby's brain adequate space to grow and develop.
5.e. Pierre Robin Sequence

Pierre Robin Sequence (PRS) is a defect characterized by retroposition of the tongue and
mandible, which often results in neonatal respiratory and feeding problem.
Pierre Robin sequence is a condition present at birth, in which the infant has a smaller
than normal lower jaw (micrognathia), a tongue that is placed further back than normal
(glossoptosis), and an opening in the roof of the mouth (cleft palate). This combination
of features can lead to difficulty breathing and problems with eating early in life. Pierre
Robin sequence may occur alone (isolated) or be associated with a variety of other signs
and symptoms (described as syndromic).
In about 20 to 40 percent of cases, the condition occurs alone. The exact causes of Pierre
Robin syndrome are unknown. Changes (mutations) in the DNA near the SOX9 gene are
the most common genetic cause of isolated cases of Pierre Robin sequence. Treatment is
focused on the specific needs of each patient, but may include surgery to assist with
breathing and feeding modifications to prevent choking.
Surgical Intervention/
Procedure

In moderate cases, the patient may need to have a tube placed through the nose and
into the airways to avoid airway blockage. In severe cases, a surgery called
distraction osteogenesis of the lower jaw is needed to prevent a blockage in the
upper airway. This is called neonatal jaw (mandibular) distraction. 
Mandibular distraction is a procedure involving surgically cutting the lower jaw
bone and placing either an internal (in the mouth) or external (through the skin)
device. This device can be slowly adjusted to lengthen the jaw thus increasing the
size of the lower jaw which in turn, pulls the tongue out of the back of the throat.
This helps to resolve obstructive sleep apnea and potentially avoid tracheostomy.
Alternatively, some patients still may need surgery to make a hole in the windpipe
(tracheostomy).
5. d. Cleft Lip & Palate

Cleft Lip (CL) with or without Cleft Palate (CP) is the most common birth defect in
U.S. and occurs with a frequency of 1 in 600 live births.
Together, these birth def ects commonly are called “orofacial clefts”.
Isolated CL with or without CP is more common in males, and CP alone is more
common in females.
Etiology
Most cases of CL and/or CP result from a combination of genetic and environmental
factors. The gene/s responsible for clefting in individuals without syndromes is not
yet known. However, some genetic syndromes are known to be associated with
clefting in approximately 15% of individuals with clefts.
 Comparison of Cleft Lip & Cleft Palate
Cleft Lip
Incidence 1:600
Inheritance Multifactorial inheritance, environmental factors,
familial occurrence.
Anatomy Unilateral or Bilateral, may involve external nose,
nasal cartilages, nasal septum, maxillary alveolar
ridges, and dental anomalies.
Management Repair at approximately 2-3 months.
Short-term Poblems Feeding and weight gain.
Special Post-operative Care Suture line protection and care, position on right side
or upright in infant seat; avoid prone position to
protect suture line.
Special feeding – slow-flow nipple, plastic
squeezable bottle, syringe feeding until it heals.
Care of suture line in postoperative period with
massage (after 2-3 weeks) and tape.
Long-term problems Social acceptance (depends on the succes of repair).
Dental or orthodontic if associated with cleft palate.
Cleft Palate
1:2500
Associated with syndrome (chromosomal), familial occurrence:
environmental factors such as maternal alcohol ingestion,
smoking or teratogens.
Soft Palate and/or Hard Palate, midline of posterior plate, may
involve nostril and absence of nasal septal development.
Repair for isolated CP between 6 to 12 months; infants with
CL/CP between 9 to 15 months.
Feeding efficiency and growth failure.
Feeding cup, syringe, special needs feeder, pigeon bottle, cleft
palate nurser, avoid spoon, fork.
Speech, otitis media, middle ear effusion, possible hearing loss,
upper respiratory tract infections.
Orthodontic or dental
Feeding
Social acceptance
Cleft lip and cleft palate happen very early in pregnancy. Normally the baby's
lips form between 4 and 7 weeks of pregnancy, and the palate forms between 6
and 9 weeks of pregnancy.
6. Dermatologic Problems in the
Newborn
6.a. Erythema Toxicum Neonatorum
Erythema toxicum neonatorum is a common
rash in neonates. It appears in up to half of
newborns carried to term, usually between day
2–5 after birth; it does not occur outside the
neonatal period.
Erythema toxicum is characterized by blotchy
red spots on the skin with overlying white or
yellow papules or pustules. These lesions may
be few or numerous. The eruption typically
resolves within first two weeks of life and
frequently individual lesions will appear and
disappear within minutes or hours. It is a
benign condition thought to cause no
discomfort to the baby.
No treatment is necessary for erythema toxicum
neonatorum as the lesions will regress in 5-14
days. Simple reassurance is given to the parents
regarding the benign temporary nature of this skin
condition.
6.b. Candidiasis
Candidiasis, also known as moniliasis, is not
uncommon in the newborn. Candida albicans, the
organism usually responsible, may cause disease in
any organ system. It is a yeast-like-fungus
(produces yeast cells and spores) that can be
acquired from a maternal vaginal infection during
delivery; by person-to-person transmission; or from
contaminated hands, bottles, nipples, or other
articles. Mucocutaneuos, cutaneous, and
disseminated candidiasis are observed in this age-
group. It is usually a benign disorder in the neonate
and is often confined to oral and diaper regions.
6.c. Oral Candidiasis

Newborns can have symptoms of Candida at

birth or soon after. 
Thrush often appears in the mouth in the first
few weeks or months of life. If the nipples of a
breast-feeding mother are affected, the
infection may be passed on to the infant.
Oral thrush is the most common oral fungal
infection in infants and children.
Treatment
Antifungal drugs are used to treat candidiasis. The antibiotic nystatin is often prescribed for children with
superficial infections such as oral thrush or a Candida-related diaper rash. The specific medicines given
for candidiasis vary, depending on the part of the body where the infection is concentrated.
For example:
Mouth and airway (associated with a weakened immune system): nystatin, clotrimazole, fluconazole,
itraconazole
Esophagus: nystatin, fluconazole, itraconazole
Skin: topical medicines such as nystatin, miconazole, clotrimazole, naftifine, and ketoconazole, among
others
Vagina: topical clotrimazole, miconazole, butoconazole, terconazole, tioconazole
If candidiasis has spread through the bloodstream to various parts of the body, your pediatrician will
usually recommend treatment with an intravenous medicine such as amphotericin B. This medicine causes
many side effects, but it is still a reliable medicine for serious, invasive fungal infections.
Treatment
6.d. Herpes Simplex Virus

Neonatal herpes is a herpes infection in a

young baby.
The younger the baby, the more vulnerable
they are to the harmful effects of infection.
It's caused by the herpes simplex virus, a
highly contagious virus that can cause cold
sores and genital ulcers in adults.
Herpes can be very serious for a young
baby, whose immune system will not have
fully developed to fight off the virus.
 How does a newborn baby
catch herpes?
During pregnancy and labour
A newborn baby is at risk of catching herpes
if the mother had genita herpes for the first
time within the last 6 weeks of her pregnancy.
There's a risk the mother will have passed the
infection on to her baby if she had a vaginal
delivery.  first 4 weeks after birth.
This risk is much lower if the mother has had
genital herpes before.
After birth
The herpes simplex virus can be passed to a baby through
a cold sore if a person has a cold sore and kisses the baby.
The herpes virus can also be spread to the baby if a mother
has a blister caused by herpes on her breast and she feeds
the baby with the affected breast or expressed breast milk
from the affected breast.
A baby is most at risk of getting a herpes infection in the
You should not kiss a baby if you have a cold sore to
reduce the risk of spreading infection.
Cold sores and other blisters caused by the herpes virus are
at their most contagious when they burst. They remain
contagious until completely healed.
Treatment
How is neonatal herpes treated?
Neonatal herpes is usually treated with antiviral drugs given directly into the
baby's vein (intravenously). 
This treatment may be needed for several weeks.
Any related complications, such as fits (seizures), will also need to be treated.
The baby can be breastfed while receiving treatment, unless the mother has herpes
sores around her nipples.
If the mother is taking antiviral treatment too, this can be excreted in her breast
milk, but is not thought to cause any harm to the baby.
How serious is herpes for a baby?
Sometimes neonatal herpes will only affect the baby's eyes, mouth or skin.
In these cases, most babies will make a complete recovery with antiviral treatment.
But the condition is much more serious if it's spread to the baby's organs.
Nearly a third of infants with this type of neonatal herpes will die, even after they
have been treated. 
If widespread herpes is not treated immediately, there's a high chance the baby will
die.
How can neonatal herpes be prevented?
If you're pregnant and have a history of genital herpes, tell your doctor or midwife. 
You may need to take medication during the last month of pregnancy to prevent an outbreak
of vaginal sores during labour.
Delivery by caesarean sectiocoming n is recommended if the genital herpes has occurred for
the first time in the last 6 weeks of your pregnancy.
If you develop a cold sore or think you're down with a herpes infection, take these
precautions:
do not kiss any babies
wash your hands before contact with a baby
wash your hands before breastfeeding
cover up any cold sores to avoid accidentally touching your mouth and then breast – this is
enough to transfer the virus
6.E Bullous Impetigo

Bullous Impetigo is an infectious

superficial skin condition most often
cause by various strains of
Staphylococcus Aureus. Bullous
vesicular lesions erupt on previously
untraumatized or intact skin. The lesions
may appear on any surface of the body
and sometimes become widespread, but
the usual distribution involves the
buttocks, perineum, trunk, face, and
extremities. The neonatal form may
appear first in the diaper region.