NCM 109: MIDTERMS Risk factors

Nursing care of the High Risk Newborn to Maturity

•Often, the exact cause of premature birth isn't clear. But certain
Problems during Maturity things can raise the risk.
•Some risk factors linked to past and present pregnancies include:
•Prematurity •Pregnancy with twins, triplets or other multiples.
•Postmaturity •A span of less than six months between pregnancies. It's ideal to
wait 18 to 24 months between pregnancies.
•Treatments to help you get pregnant, called assisted reproduction,
Prematurity including in vitro fertilization.
•More than one miscarriage or abortion.
-A premature birth means a baby is born too early. The
•A previous premature birth.
birth takes place before the 37th week of pregnancy. A typical
pregnancy lasts about 40 weeks. Some health problems can raise the risk of premature birth, such
as:
-Premature babies often have serious health problems,
especially when they're born very early. These problems often vary. •Problems with the uterus, cervix or placenta.
But the earlier a baby is born, the higher the risk of health •Some infections, mainly those of the amniotic fluid and lower
challenges. genital tract.
•Ongoing health problems such as high blood pressure and diabetes.
•Injuries or trauma to the body.

Lifestyle choices also can raise the risk of a preterm pregnancy,

such as:

•Smoking cigarettes, taking illicit drugs or drinking alcohol often or

heavily while pregnant.
•Being underweight or overweight before pregnancy.
•Becoming pregnant before the age of 17 or after 35.
•Going through stressful life events, such as the death of a loved one
or domestic violence.
•For unknown reasons, Black and Native people in the United States
A newborn can be: are more likely to have premature births than are women of other
Late preterm, born between 34 and 36 completed weeks of races. But premature birth can happen to anyone. In fact, many
pregnancy. preterm births have no known risk factors.

Moderately preterm, born between 32 and 34 weeks of pregnancy. Complications

Very preterm, born between 28 and 32 weeks of pregnancy. •Not all premature babies have health complications. But being born
too early can cause short-term and long-term medical problems. In
Extremely preterm, born before 28 weeks of pregnancy. general, the earlier a baby is born, the higher the risk of
complications. Birth weight plays a key role too.
Most premature births happen in the late preterm stage.
•Some problems may be clear at birth. Others may not show up until
Symptoms later.
Your baby may have very mild symptoms of premature Short-term complications
birth or more-serious health problems.
In the first weeks, the complications of premature birth may include:
Some signs of being born too early include:
•Breathing problems. A premature baby may have trouble breathing
•Small size, with a head that's large compared with the body. due to being born with lungs that aren't fully developed. If the
•Features that are sharper and less rounded than a full-term baby's baby's lungs lack a substance that allows the lungs to expand, the
features due to a lack of cells that store fat. baby may have trouble getting enough air. This is a treatable problem
called respiratory distress syndrome.
•Fine hair that covers much of the body.
•It's common for preterm babies to have pauses in their breathing
•Low body temperature, mainly right after birth in the delivery
called apnea. Most infants outgrow apnea by the time they go home
room.
from the hospital. Some premature babies get a less common lung
•Trouble breathing. disorder called bronchopulmonary dysplasia. They need oxygen for a
few weeks or months, but they often outgrow this problem.
•Feeding problems.
•Heart problems. Some common heart problems that premature
The following tables show the median birth weight, length and head babies have are patent ductus arteriosus (PDA) and low blood
circumference of premature babies at different gestational ages for pressure. PDA is an opening between two important blood vessels,
each sex. the aorta and the pulmonary artery. This heart defect often closes on
its own. But without treatment it can lead to problems such as heart
failure. That's when the heart can't pump blood as well as it should.
Low blood pressure may need to be treated with fluids given through
a vein, medicines and sometimes blood transfusions.

•Brain problems. The earlier a baby is born, the greater the risk of
bleeding in the brain. This is called an intraventricular hemorrhage.
Most hemorrhages are mild and resolve with little short-term
impact. But some babies may have larger brain bleeding that causes
permanent brain injury.

•Temperature control problems. Premature babies can lose body

heat quickly. They don't have the stored body fat of a full-term
infant. And they can't make enough heat to counter what's lost
through the surface of their bodies. If body temperature drops too
low, it can lead to a dangerous problem called hypothermia.
•Hypothermia in a premature baby can lead to breathing problems •Taking progesterone supplements. Progesterone is a hormone that
and low blood sugar levels. A preterm infant also may use up all of plays a role in pregnancy. A lab-made version of it may be able to
the energy gained from feedings just to stay warm. That's why lower the risk of preterm birth if you've had a premature baby
smaller premature babies need extra heat from a warmer or an before. It also may lower the risk of preterm birth if you have a short
incubator at first. cervix. The cervix is the lower end of the uterus, which opens during
labor so a baby can be born.
•Digestive problems. Premature infants are more likely to have
digestive systems that aren't fully developed. This can lead to Cervical cerclage
problems such as necrotizing enterocolitis (NEC). With NEC, the cells
lining the bowel wall are injured. This problem can happen in •This is a surgery that's done during pregnancy. Your provider may
premature babies after they start feeding. Premature babies who suggest it if you have a short cervix and you've had a preterm birth
receive only breast milk have a much lower risk of getting NEC. before.

•Blood problems. Premature babies are at risk of blood problems •During this procedure, the cervix is stitched closed with a strong
such as anemia and newborn jaundice. With anemia, the body suture. This may give the uterus extra support. The suture is
doesn't have enough red blood cells. All newborns have a slow drop removed when it's time to have the baby. Ask your provider if you
in red blood cell count during the first months of life. But that drop need to stay away from vigorous activity during the rest of your
may be greater in premature babies. With newborn jaundice, the pregnancy.
skin and eyes look yellow. It happens because the baby's blood
•One thing that doesn't help prevent preterm birth is staying in bed.
contains too much of a yellow-colored substance from the liver or
Bed rest can raise the risk of blood clots, weaker bones and less
red blood cells. This substance is called bilirubin. Jaundice has many
muscle strength. It might even make preterm birth more likely.
causes, but it is more common in preterm babies.
Postmaturity
•Metabolism problems. Premature babies often have problems with
metabolism. That's the process by which the body changes food and •The normal length of pregnancy is from 37 to 41 weeks.
drink into energy. Some premature babies may have a very low level Postmaturity refers to any baby born after 42 weeks gestation or 294
of blood sugar. This can happen because premature infants often days past the first day of the mother's last menstrual period. Less
have smaller amounts of stored blood sugar than do full-term than 6 percent of all babies are born at 42 weeks or later. Other
babies. Premature babies also have more trouble turning their terms often used to describe these late births include post-term,
stored sugar into more-usable, active forms of blood sugar. postmaturity, prolonged pregnancy, and post-dates pregnancy.
•Immune system problems. It's common for premature babies to
have immune systems that aren't fully developed. This can lead to a
higher risk of illnesses. An infection in a premature baby can quickly
spread to the bloodstream and cause a life-threatening problem
called sepsis.

Long-term complications

Over the long term, premature birth may lead to health problems What causes postmaturity?
such as:
•It is not known why some pregnancies last longer than others.
•Cerebral palsy. This group of disorders can cause problems with Postmaturity is more likely when a mother has had one or more
movement, muscle tone or posture. It can be due to an infection or previous post-term pregnancies. Sometimes a mother's pregnancy
poor blood flow. It also can stem from an injury to a newborn's brain, due date is miscalculated because she is not sure of her last
either early during pregnancy or while the baby is still young. menstrual period. A miscalculation may mean the baby is born
earlier or later than expected.
•Trouble learning. Premature babies are more likely to lag behind
full-term babies on different milestones. A school-age child who was Why is postmaturity a concern?
born too early might be more likely to have learning disabilities.
•Postmature babies are born after the normal length of pregnancy.
•Vision problems. Premature infants may get an eye disease called The placenta, which supplies babies with the nutrients and oxygen
retinopathy of prematurity. This happens when blood vessels swell from the mother's circulation, begins to age toward the end of
and grow too much in the light-sensing tissue at the back of the eye, pregnancy, and may not function as efficiently as before. Other
called the retina. Sometimes these overgrown vessels slowly scar the concerns include the following:
retina and pull it out of place. When the retina is pulled away from
the back of the eye, it's called retinal detachment. Without •Amniotic fluid volume may decrease and the fetus may stop gaining
treatment, this can harm vision and cause blindness. weight or may even lose weight.

•Hearing problems. Premature babies have a higher risk of losing •Risks can increase during labor and birth for a fetus with poor
some hearing. All babies should have their hearing checked before oxygen supply.
they go home from the hospital.
•Problems may occur during birth if the baby is large.
•Dental problems. Preterm babies may be more likely than full-term
•Postmature babies may be at risk for meconium aspiration, when a
babies to have defects with the hard outer covering of the teeth,
baby breathes in fluid containing the first stool.
called enamel. Infants born very or extremely early also may be
more likely to have teeth that take longer to develop. •Hypoglycemia (low blood sugar) can also occur because the baby
has already used up its glucose-producing stores.
•Behavior and mental health problems. Children who were born
early may be more likely than kids born full term to have certain What are the symptoms of postmaturity?
mental health troubles, as well as delays in development.
•The following are the most common symptoms of postmaturity.
•Ongoing health issues. Premature babies are more likely to have However, each baby may show different symptoms of the condition.
long-term health issues than are full-term infants. Illnesses, asthma Symptoms may include:
and feeding problems are more likely to develop or linger. Premature
infants also are at higher risk of sudden infant death syndrome •Dry, loose, peeling skin
(SIDS). That's when an infant dies for unclear reasons, often while
asleep. •Overgrown nails

Prevention •Abundant scalp hair

The exact cause of preterm birth is often unknown. But some things •Visible creases on palms and soles of feet
can be done to help lower the risk of preterm birth, including:
•Minimal fat deposits
•Green, brown, or yellow coloring of skin from meconium staining they should. Some of the problems that cause babies to be small for
(the first stool passed during pregnancy into the amniotic fluid) gestational age limit how much blood flows through the placenta.
This can cause the baby to get less oxygen than normal. This
•More alert and "wide-eyed" increases the baby’s risks during pregnancy and delivery, and later.
Things that can cause babies to be small for gestational age are listed
•Symptoms of postmaturity may resemble other conditions or
below.
medical problems. Always consult your baby's doctor for a diagnosis.

How is postmaturity diagnosed?

Problems with the mother
•Postmaturity is usually diagnosed by a combination of assessments,
•High blood pressure
including the following:
•Chronic kidney disease
•Your baby's physical appearance Diabetes
•Heart disease or respiratory disease
•Length of the pregnancy •Malnutrition or anemia
Infection
•Your baby's assessed gestational age •Alcohol or drug use
•Cigarette smoking
Treatment of postmaturity •Weighing less than 100 pounds
•Testing may be done for a post-term pregnancy to check fetal well-
being and identify problems. Tests often include ultrasound, Problems with the uterus and placenta
nonstress testing (how the fetal heart rate responds to fetal activity), •Decreased blood flow in the uterus and placenta
and estimation of the amniotic fluid volume. •Placenta detaches from the uterus
•The decision to induce labor for post-term pregnancy depends on •Placenta attaches low in the uterus
many factors. During labor, the fetal heart rate may be monitored •Infection in the tissues around the baby
with an electronic monitor to help identify changes in the heart rate
due to low oxygenation. Changes in a baby's condition may require a Problems with the developing baby
cesarean delivery.
•Multiple pregnancy, such as twins or triplets
•Special care of the postmature baby may include: •Infection
•Checking for respiratory problems related to meconium (baby's first •Birth defects
bowel movement) aspiration. •Chromosome problems

•Blood tests for hypoglycemia (low blood sugar). What are the symptoms of small for gestational age babies?

•Small for gestational age babies may look mature, but they are
Prevention of postmaturity smaller than other babies of the same gestational age. They may be
small all over, or they may be of normal length and size but have
•Accurate pregnancy due dates can help identify babies at risk for lower weight and body mass. These babies may be born:
postmaturity. Ultrasound examinations early in pregnancy help
establish more accurate dating by measurements taken of the fetus. •Premature. Before 37 weeks of pregnancy.
Ultrasound is also important in evaluating the placenta for signs of •Full-term. Between 37 and 38 weeks (early term) through 41
aging. weeks.

•Post-term. After 42 weeks of pregnancy.

Problems related to gestational weight
•Many small for gestational age babies have low birth weight. But
•Small for Gestational Age (SGA) not all are premature. They may not have the same problems as
•Large for Gestational Age (LGA) premature babies. Other babies, especially those with intrauterine
growth restriction, may look thin and pale, and have loose, dry skin.
The umbilical cord is often thin and dull-looking rather than shiny
Small for Gestational Age and fat.

•Small for gestational age is a term used to describe babies who are How are small for gestational age babies diagnosed?
smaller than usual for the number of weeks of pregnancy. These
babies have birth weight below the 10th percentile. This means they •Babies with this problem are often diagnosed with intrauterine
are smaller than many other babies of the same gestational age. growth restriction before birth. During pregnancy, a baby’s size can
Many babies normally weigh more than 5 pounds, 13 ounces by the be guessed in different ways. The height of the top of a mother’s
37th week of pregnancy. Babies born weighing less than 5 pounds, 8 uterus can be measured from the pubic bone. This measurement in
ounces are considered low birth weight. centimeters usually links with the number of weeks of pregnancy
after the 20th week. If the measurement is low for the number of
What causes babies to be small for gestational age? weeks, then the baby may be smaller than expected.

•Some babies are small because their parents are small. But most •Other tests used for diagnosis may include:
babies who are small for gestational age have growth problems that
happen during pregnancy. Many of these babies have a condition •Ultrasound to estimate the baby’s size
called intrauterine growth restriction. This happens when •Doppler flow to help check blood flow to the baby during
the unborn baby doesn’t get the nutrients and oxygen needed to pregnancy
grow and develop organs and tissues. This can begin at any time in
pregnancy. •Mother’s weight gain to tell how a baby is growing during
pregnancy
•Growth restriction early in pregnancy (early onset) happens
because of chromosome problems in the baby. It also happens •Baby’s birth weight as compared with the gestational age once the
because of disease in the mother,or severe problems with the baby is born. The healthcare provider may use a formula to figure
placenta. Growth restriction is called late onset if it happens after out the baby’s body mass.
week 32 of the pregnancy. It is usually related to other problems.
How are small for gestational age babies treated?

Who is at risk for being small for gestational age? •Treatment will depend on your child’s symptoms, age, and general
health. It will also depend on how severe the condition is.
•When the unborn baby doesn’t get enough oxygen or nutrients
during pregnancy, the baby’s body and organs don't grow as much as •Babies with this problem may be physically more mature than their
small size would suggest. But they may be weak and less able to take baby's insulin levels stay high.
large feedings or stay warm. Treatment may include:

•Temperature-controlled beds or incubators Which babies are at risk for LGA?

•Tube feedings if the baby does not have a strong suck •If a baby is too large to fit through the birth canal easily, birth can
be difficult. Problems at birth may include:
•Blood tests to check for low blood sugar
•Long time for delivery
•Watching oxygen levels
•Difficult birth
•Babies who are also premature may have other needs. They may •Injury to the baby, such as a broken collar bone or damaged nerves
need oxygen and a breathing machine (ventilator). in the arm (brachial plexus)
•Increased need for a cesarean section deliver
What are the complications of being small for gestational age?
Many large babies are born to mothers with diabetes. Poor control
•Babies who are small for gestational age or who have intrauterine of blood sugar may cause problems such as:
growth restriction may have problems at birth. These can include:
•Lower oxygen levels than normal •Low blood sugar in the baby in the first several hours after birth
•Low Apgar scores •A higher risk for birth defects
•Breathing in the first stools (meconium) passed in the womb. This •Trouble breathing
can cause breathing problems.
-Babies who are large for gestational age may also be more likely to
•Low blood sugar
have yellowing of the skin, eyes, and mucous membranes (jaundice).
•Difficulty keeping a normal body temperature
•Too many red blood cells What are the symptoms of LGA?

Can small size for gestational age be prevented? •Babies may be called large for gestational age if they weigh more
than 9 in 10 babies or 97 of 100 babies of the same gestational age.
•Prenatal care is important in all pregnancies. It is especially helpful In the U.S., this means babies born at 40 weeks' gestation who weigh
to see any problems with the baby’s growth. For a healthy more than 8 pounds 13 ounces (4,000 grams) or 9 pounds, 11
pregnancy, stop smoking if you smoke, and don't use drugs or ounces (4,400 grams) at birth.
alcohol while you are pregnant. Eating a healthy diet during
pregnancy may also help. How is LGA diagnosed?

Key points about small for gestational age babies •Babies with this problem are often diagnosed before birth. During
pregnancy, a baby’s size can be estimated in different ways. The
•Small for gestational age means a baby is smaller than expected for height of the top of a mother’s uterus can be measured from the
the number of weeks of pregnancy. pubic bone. This measurement in centimeters usually links with the
number of weeks of pregnancy after the 20th week. If this
•Although some babies are small because their parents are small, measurement is high for the number of weeks, the baby may be
most babies who are small for gestational age have growth problems larger than expected. Before the baby is born, healthcare providers
that happen during pregnancy. use the term fetal macrosomia instead of LGA.

•When the unborn baby does not get enough oxygen or nutrients Other ways to check the baby’s growth before birth include:
during pregnancy, he or she does not grow as much as normal.
•Ultrasound.This test uses sound waves to create a picture of your
•The condition is often suspected before birth. baby and the inside of your body. It is a more accurate method of
estimating the size of your baby, but it's still not exact.
•Prenatal care is important in all pregnancies. It is especially helpful Measurements can be taken of your baby’s head, belly (abdomen),
to see any growth problems of the developing baby. and upper leg bone to see how fast he or she is growing.
What is large for gestational age (LGA)? •Weight gain during pregnancy. This can also affect your baby's size.
Gaining a lot of weight during pregnancy may cause your baby to be
•Large for gestational age (LGA) is used to describe newborn
bigger than normal.
babies who weigh more than usual for the number of weeks of
pregnancy. Babies may be called large for gestational age if they •Babies are weighed within the first few hours after birth. The
weigh more than 9 in 10 babies (90th percentile) or more than 97 of weight is compared with the baby's gestational age and recorded in
100 babies (97th percentile) of the same gestational age. This is the medical record.
based on U.S. statistics from 1991. About 1 in 10 babies born at 40
weeks' gestation in the U.S. in 1991 weighed more than 8 pounds, 13 How is LGA treated?
ounces (4,000 grams) at birth. Three in 100 babies weighed more
than 9 pounds, 11 ounces 4,400 grams). •Treatment will depend on your child’s symptoms, age, and general
health.
•Babies born earlier than 40 weeks are considered LGA at lighter
weights. Babies born after 40 weeks are considered LGA at slightly •If ultrasound exams during pregnancy show that your baby is very
higher weights. Overall, babies born in the U.S. in recent years weigh large, your healthcare provider may recommend early delivery. You
a little more than they used to. Normal ranges for birth weight may may need a planned cesarean section.
also be different, based on ethnic background. •After birth, a baby who is large for gestational age will be carefully
What causes babies to be LGA? checked for any injuries that happened during birth. Your baby may
have blood glucose testing for at least the first 12 hours to check for
•Some babies are large because their parents are large. Parents may low blood sugar.
pass along this trait to their children. A high birth weight can also be
related to the amount of weight a mother gains during pregnancy. What are possible complications of LGA?
Women who gain a lot of weight during pregnancy often give birth to •Babies who are large for gestational age are at higher risk for a
babies who are large for gestational age. breathing problem called respiratory distress syndrome. They also
•Diabetes in the mother is the most common cause of babies who may be at risk of breathing meconium into the lungs around the time
are large for gestational age. When a pregnant woman has high of birth.
blood sugar, she can pass that along to her baby. In response, the •Birth injuries such as a broken collar bone or damaged nerves in the
baby's body makes insulin. All the extra sugar and the extra insulin arm (brachial plexus) are more common in babies who are very large
that is made can lead to fast growth and deposits of fat. This means for gestational age. These babies also may need to stay in neonatal
a larger baby. It also means a risk for low blood sugar right after intensive care because of breathing problems, low blood sugar
birth. At that point, the mother's supply is no longer there, but the (hypoglycemia), or both. The risk for problems increases as the birth
weight increases. The risks are highest for babies who weight more What causes RDS?
than 9 pounds 15 ounces (4,500 grams).
-RDS is caused by a lack of surfactant in the lungs. The lungs of a
•LGA babies are more likely to have an excessive amount of red fetus start making surfactant during the third trimester, which starts
blood cells (polycythemia). As these red blood cells break down, after the 26th week of pregnancy.
their livers may not be able to handle the increased about of
bilirubin needing to be conjugated. This may result in high levels of •Surfactant is a foamy substance that keeps the lungs fully expanded
bilirubin in the blood resulting in jaundice. so that newborns can breathe in air once they are born. Without it,
the lungs collapse, and the newborn must work hard to breathe. This
How can LGA be prevented? can cause the baby’s organs to be without necessary levels of
oxygen.
•Regular prenatal care is important in all pregnancies. Regular
checkups can help your healthcare provider find out how your baby •If a full-term baby develops RDS, it may be because they have faulty
is growing. If your baby seems large, it may be a sign that you have genes that affect how their bodies make surfactant.
undetected diabetes or other problems. To lower some of the risks
to your baby: How is RDS treated?

•Take care of your diabetes -The earlier a baby is born, the more likely they are to have RDS that
cannot be prevented. Nearly all babies born before 28 weeks of
•Watch your weight pregnancy will have RDS. With treatment, many newborns that are
•Follow your healthcare provider’s advice diagnosed with RDS will recover.

Key points about large for gestational age Some common treatments include those listed below.

•Babies are called large for gestational age if they weigh more than •Nasal continuous positive airway pressure (nCPAP): This device
expected for their gestational age (weeks of pregnancy) at birth. provides breathing support by gently pushing air into the baby's
•Diabetes is the most common cause of babies who are large for lungs through prongs placed in the nose.
gestational age.
•If a baby is too large to fit through the birth canal easily, delivery •Surfactant replacement therapy: This can be used if a newborn
can be difficult. struggles to breathe despite the use of nCPAP. Sometimes, giving an
•If ultrasound exams during pregnancy show a baby is very large, infant surfactant requires the use of a breathing tube. If so, because
your healthcare provider may recommend early delivery. of the possible complications, your baby’s provider will help you
•Regular prenatal checkups can help your healthcare provider find consider the risks and benefits of the procedure.
out if your baby is too large.
•Mechanical ventilation: This is used only in very serious cases of
•Acute conditions of the neonates
RDS. A ventilator is a machine that takes over the work of breathing
•Respiratory Distress Syndrome
and is a form of life support. The machine connects to a breathing
•Meconium aspiration syndrome
tube that runs through a newborn’s mouth or nose and into the
•Sepsis
windpipe. Babies that require ventilation are more likely to develop
• Hyperbilirubinemia
bronchopulmonary dysplasia. They may also develop health
•Sudden death syndrome (SDS )
problems from the breathing tube or ventilator, such as an airway or
lung injury.
NEWBORN BREATHING CONDITIONS •Fluids and nutrients: These may be given to help prevent
Respiratory Distress Syndrome (RDS) malnutrition and promote growth. Nutrition is critical to the growth
and development of the lungs.
-RDS is a common breathing disorder that affects newborns. RDS
occurs most often in babies born before their due date, usually If a baby born with RDS still requires breathing support by the time
before 28 weeks of pregnancy. Less often, RDS can affect full-term they reach their original due date, they are diagnosed with a
newborns. condition called bronchopulmonary dysplasia.

-Depending on how serious their RDS is, they may also develop other
medical conditions, including:

•Bleeding in the brain, which can delay cognitive development or

cause intellectual disabilities or cerebral palsy

•Lung complications, such as air leaking from the lung into the chest
cavity, called pneumothorax, or bleeding in the lungs
•Impaired vision
•Infections that can cause sepsis

What are the symptoms? Meconium Aspiration Syndrome

Symptoms of RDS include: -Meconium aspiration syndrome (MAS) is the neonatal respiratory
•Fast and shallow breathing distress that occurs in a newborn in the context of meconium-
•Grunting stained amniotic fluid (MSAF) when respiratory symptoms cannot be
•Flaring of the nostrils with each breath attributed to another etiology. This activity describes the
•Bluish tone to a baby’s skin and lips pathophysiology, presentation, and management of meconium
•Pulling inward of the muscles between the ribs when breathing aspiration syndrome and highlights the importance of an
interprofessional team approach in improving care for and
How will a doctor find out whether a newborn has RDS? decreasing morbidity in patients with this condition.

-RDS is common in premature newborns, but doctors may need to Etiology

run tests to rule out other types of newborn breathing conditions.
After doing a physical examination to look at a newborn’s symptoms, -MAS is due to the aspiration of meconium-stained amniotic fluid.
your provider may order one or more of the tests below. MSAF is not an uncommon finding and is not always associated with
MAS.[3] Uterine stress due to hypoxia or infection can cause early
•Lung imaging tests such as chest X-rays show how well the lungs fetal meconium passage. Unlike infant stool, meconium is darker and
and heart are working. X-rays are used to diagnose most types of thicker. It is formed through the accumulation of fetal cellular debris
newborn breathing conditions. (skin, gastrointestinal, hair) and secretions.[4] Aspiration of these
•Heart tests such as an echocardiogram can check for a possible materials causes airway obstruction, triggers inflammatory changes,
congenital heart defect. and inactivates surfactant. Through these mechanisms, the neonate
•Blood tests look for an infection. develops respiratory distress.
Pathophysiology -Arterial blood gas (ABG): ABG is a tool to assess the
degree of respiratory failure and help guide management
-The pathophysiology of MAS is not completely understood. (intubation, mechanical ventilation). In severe cases, ABG will show
However, 5 important processes have been described: Meconium hypoxemic, hypercapnic, and respiratory acidosis.
passage, aspiration, airway obstruction, inflammation, and surfactant
inactivation. -Pulse oximetry: To assess oxygenation but also the degree
of shunting (pre-ductal and postductal differential).
-Meconium passage: Usually, fecal defecation rarely happens
between 20 and 34 weeks of gestation.[8] It was noticed that in -Echocardiography (ECG): ECG is an important tool to
utero meconium passage is more common in late-term and post- assess heart function and help screen for signs of PPHN and right
term babies after 37 weeks of gestation.[9] Several mechanisms have ventricular dysfunction. It also helps identify the cardiac anatomy
been hypothesized to play a role in the process, including increased and evaluate for any cardiac level right to left shunting.
peristalsis, anal sphincter relaxation, and changes in vagal and
sympathetic tones in the context of fetal distress and hypoxia. -Blood and tracheal cultures: Evaluation for sepsis and
pneumonia is crucial in the context of neonatal distress. Often
Aspiration: During the delivery process, fetal breathing usually leads empiric antibiotics are started.
to amniotic fluid moving in and out of the lungs. When amniotic fluid
is stained with meconium, the fetus is at risk of aspiration. This is MAS management is mainly supportive, but early identification and
especially true with hypoxia, which can trigger the fetus to increase support can improve outcomes and decrease morbidity and
gasping, which leads to more amniotic fluid inhalation by the fetal mortality. This requires an interprofessional team approach,
airway.[10] including the obstetrician, midwife, neonatologist,respiratory
therapist, nurse, pediatric pulmonologist, and pediatric cardiologist.
Airway obstruction: As meconium is thick and the fetal airways are
small in diameter, the presence of meconium in the airways can -Oxygen therapy: Supplemental oxygen is often needed in MAS with
cause obstruction. The mechanism is similar to a foreign body goal oxygen saturation > 90% to prevent tissue hypoxia and improve
aspiration. The meconium plug can cause complete obstruction oxygenation. Hypoxemia is an important trigger of pulmonary
leading to lung collapse distally as well as atelectasis. When partial vasoconstriction, which can increase PVR and worsen PPHN.
obstruction occurs, it causes a ball valve effect with increased air
-Ventilatory support: This is indicated with refractory hypoxemia
trapping, thus increasing the risk of air leak syndromes, notably
despite oxygen therapy, carbon dioxide retention, and increased
pneumothorax. Recent data suggest that airway obstruction does
respiratory distress. It also has a role for respiratory support in PPHN
not always happen in the context of MSAF and that obstruction
and air leak syndromes. There are no specific ventilation strategies.
alone does not completely explain MAS.[11]
Oxygenation monitoring and serial ABG to help optimize oxygenation
Inflammation: Inflammation plays an important role in the and ventilation are key. In severe cases with refractory hypoxemia,
pathogenesis of MAS. Material that constitutes meconium has been the patient might require extracorporeal membrane oxygenation
shown to trigger inflammatory processes that further contribute to (ECMO) for cardiorespiratory support.
the development of respiratory distress in MAS. Airway inflammation
-Surfactant: The use of surfactant in MAS is not standard of care;
results in a form of chemical pneumonitis. Matrix metalloproteinase-
however, as discussed above, surfactant inactivation has a role in the
8, interleukin-6, interleukin-8, interferon-gamma, and tumor necrosis
pathogenesis of MAS. Therefore surfactant may be helpful in some
factor-alpha have all been described to be significantly higher in
cases.[2]
patients with MAS.[12][13]
-Nitric oxide: Inhaled nitric oxide is a pulmonary vasodilator that has
Surfactant inactivation: Inflammation and hydrolysis can alter and
a role in pulmonary hypertension and PPHN.
inactivate surfactant.[14] This leads to increased surface tension,
poor compliance, and impaired oxygenation. Thus, further The differential diagnosis for MAS includes other causes of
contributing to the respiratory distress seen in MAS. newborn distress:
•All these processes lead to a decrease in alveolar ventilation, •Respiratory distress syndrome: This is more common in a preterm
causing increased ventilation-perfusion mismatch. This is the main infant.
cause of hypoxemia in infants with MAS. Prolonged hypoxemia will
trigger pulmonary vascular constriction, which in turn increases •Transient tachypnea of the newborn: This usually resolves within 72
pulmonary vascular resistance (PVR). This is often accompanied by hours.
right-to-left shunting. These mechanisms can trigger PPHN.
•Sepsis/infection/pneumonia: Any newborn with distress should be
Relevant History for MAS Diagnosis assessed for infections.

•A term or post-term newborn •Congenital heart disease: Usually diagnosed with an

•Neonatal respiratory distress not otherwise explained echocardiogram.
•Meconium-stained amniotic fluid
Sepsis Neonatorum
Important Findings to Note on Physical Exam That Can Be Present •Sepsis in a newborn (sepsis neonatorum) is an infection that
With MAS spreads throughout the baby’s body. Sepsis occurs in less than 1
•Signs of postmaturity: Vernix, peeling skin, long fingernails percent of newborns (1 out of every 100), but accounts for up to 30
•Signs of respiratory distress at birth: Bradycardia, hypoxemia, percent of deaths in the first few weeks of life.
cyanosis, and tachypnea •Infection is 5-10 times more common in premature newborns and
•Birth depression: Limp or non-vigorous baby in babies weighing less than 5½ pounds than in normal-weight, full-
•Meconium-stained amniotic fluid and meconium-stain on physical term newborns. Complications experienced during birth, such as
exam premature or prolonged rupture of the membranes or infection in
Evaluation the mother, put the newborn at increased risk of infection.

-History and clinical presentation/context are key in Symptoms

suspecting a diagnosis of MAS. This is crucial, as early interventions •The onset of what is called early-onset neonatal sepsis is within six
and management can be necessary for respiratory and hours of birth in over half the cases and within 72 hours in the great
cardiovascular support. majority of cases. Sepsis that begins four or more days after birth is
Evaluation of MAS Includes called late-onset sepsis, and is probably an infection acquired in the
hospital nursery (a nosocomial infection).
-Chest radiograph (CXR): Early CXR findings are
nonspecific. These include streaky densities bilaterally. Later findings -In both types of neonatal sepsis, the infection may be only in the
on CXR include hyperinflation, flattening of the diaphragms, and bloodstream, or may spread to the lungs (pneumonia), brain
atelectasis. Pneumothorax can also be seen. (meningitis), bone (osteomyelitis), joints, or other organs in the
body. Typical symptoms of a newborn with sepsis include:
 •Listlessness (a very sleepy baby) great majority of newborns with sepsis live without any long-term
problems
•Feeding problems
SIDS Defined
•A high or low temperature
The sudden death of an infant under 1 year of age, which remains
Other symptoms include: unexplained after thorough case investigation, including
performance of a complete autopsy, examination of the death scene,
•Difficulty breathing, rapid breathing, or apnea (when the
and review of the clinical history.
baby stops breathing)
Epidemiology
•Seizures
•Unknown cause
•Excessive jitteriness
•Responsible for more infant deaths than any other cause (USA)
•Repeated vomiting or diarrhea
•despite >50% reduction since 1992
•A swollen abdomen
•Rare during the 1st month
Diagnosis
•Peaks between 2-3 months
•The organism that is causing the infection may be
identified by taking cultures of the blood as well as from other sites Risk Factors
of the body. Urine samples are often cultured for bacteria to look for
an infection in the urinary tract. Because only small samples of blood •Prone sleep position
and other body fluids are taken, sometimes no organism is found.
However, the infant may still be treated if other laboratory studies or •Sleeping on a soft surface
the infant’s clinical appearance strongly suggest an infection.
•Maternal smoking during pregnancy
Other laboratory studies that doctors use to detect an infection
•Overheating
include the following:
•Late or no prenatal care
•White Blood Cell Count and Differential: When an infant is
fighting an infection, their white blood cell count may either go up, •Young maternal age
as the infant’s body produces more infectionfighting cells, or it might
also go down if the infant has used up all of their white blood cells •Preterm birth and/or low birth weight
fighting the infection and can no longer keep up with their
production of white cells. Another change that is seen when an •Male gender
infant is fighting an infection is an increase in the percentage of AAP – Recommendations]
immature white cells. This is due to the increased production rate of American Academy of Pediatrics
white blood cells, such that more immature white blood cells are
being released into the blood stream. This higher percentage of 1. Back to sleep
immature white cells is sometimes referred to as a “left-shift,” and is
one of the things that can tell the doctors that the infant has an •Infants should be placed for sleep in a supine position for every
infection. sleep

•C-Reactive Protein (CRP): This is a laboratory test that •Side sleeping is not as safe as supine sleeping
measures a protein that is a non-specific marker for inflammation
•Not advised
and therefore infection. If the infant has two normal CRP levels
measured 24 hours apart, then there is a 99% chance that the infant AAP - Recommendations
does not have an infection. Therefore, this test is most useful in
ruling out an infection. 2. Use a firm sleep surface

•Lumbar Puncture: If the doctor suspects meningitis, which is more ◦ Firm crib mattress, covered by a sheet
common if something has grown in the baby’s blood culture, a spinal
tap, or lumbar puncture will be performed. Lumbar punctures allow ◦ Soft materials (pillows, quilts, comforters, etc.) should not be placed
the doctor to obtain a small amount of cerebrospinal fluid (CSF), under a sleeping infant
which is the protective fluid that surrounds the brain and the spinal
◦ AAP - Recommendations
cord. The CSF can then be cultured to determine if the bacteria has
spread to the nervous system. 3. Keep soft objects and loose bedding out of the crib
•The doctor, nurse practitioner, or physician’s assistant will very ◦ If bumper pads are used, should be thin, firm and well-secured
carefully insert a special spinal needle between two vertebrae, or
backbones, in the baby’s back at a level below where the actual ◦ Use sleep clothing
spinal cord ends, so there is no danger that the needle will come into
contact with the baby’s spinal cord. After a very small amount of -with no other coverage
fluid is removed, the needle is taken out, and a band-aid placed on or infant sleep sacks
the baby’s back. AAP - Recommendations
Prognosis and Treatment ◦ If blankets are used, they should be tucked so that the infant’s face is
-Sepsis in a newborn is treated with antibiotics given less likely to be covered
intravenously. Antibiotics are often started even before laboratory ◦ With infant’s feet to the
and culture results are available. The doctor may then switch to a
different antibiotic that is more specific to the baby’s infection once foot of the bed, tuck blankets in so that they
the results of laboratory tests are back. The length of antibiotic only reach the infant’s chest
treatment varies depending on the infant’s clinical status, laboratory
test results, and kind of infection. AAP - Recommendations

-If blood cultures and other laboratory tests are all 4. Do not smoke during pregnancy
negative, antibiotics may be stopped after 48 hours of treatment. If
◦ Major risk factor
the infant’s cultures are positive, or if the laboratory tests and clinical
status are suggestive of infection, the infant will be treated with ◦ Also avoid infant
antibiotics, usually anywhere from 7-14 days. When appropriately
treated with antibiotics and cared for in the intensive care unit, the -exposure to second hand smoke
 AAP - Recommendations ◦ Foster parents

5. Separate but proximate sleeping environment ◦ Babysitters

◦ Risk is reduced when infant sleeps in the same room as the mother ◦ Black and American Indian/Alaska Native populations

◦ Bed sharing is not recommended

◦ Breastfeeding/comforting - return to crib/basinet when parent is QUIZ #9

ready to return to sleep
1. PDA is an opening between two important blood vessels, the aorta
AAP - Recommendations and the pulmonary artery.
6. Offer a pacifier at nap and bedtime 2. Surfactant is a foamy substance that keeps the lungs fully expanded
so that newborns can breathe in air once they are born.
◦ Pacifier use during sleep reduces risk of SIDS
3. Echocardiography (ECG): ECG is an important tool to assess heart
◦ Mechanism unknown?
function and help screen for signs of PPHN
NOTE: Evidence that pacifier use inhibits breastfeeding or
4. Intrauterine growth restriction happens when the unborn
causes later dental complications is not strong enough at this time to
baby doesn’t get the nutrients and oxygen needed to grow and
outweigh this benefit…
develop organs and tissues.
First Year – Pacifier Use
5. Vernix caseosa is the white, cream cheese–like substance that serves
•Pacifier should be used when placing the infant down for sleep and as a skin lubricant in utero.
not be reinserted once the infant falls asleep
6. Antibiotics to prevent neonatal infection with Group B
•If the infant refuses, s/he should not be forced Streptococcus (GBS).

•Pacifiers should not be coated in any sweet solution 7. Arterial blood gas (ABG): ABG is a tool to assess the degree of
respiratory failure and help guide management
•Pacifiers should be cleaned often and replaced regularly
8. Nasal continuous positive airway pressure (nCPAP): This device
•For breastfed infants, delay pacifier introduction until 1 month of provides breathing support by gently pushing air into the baby's
age lungs through prongs placed in the nose.

•Ensure breastfeeding is firmly established 9. Inhaled nitric oxide is a pulmonary vasodilator that has a role in
pulmonary hypertension and PPHN
•AAP - Recommendations
10. C-Reactive Protein (CRP): This is a laboratory test that measures
7. Avoid overheating a protein that is a non-specific marker for inflammation and
◦ Should be lightly clothed for sleep therefore infection.

◦ Bedroom temperature should be kept comfortable for a lightly 1. Nasal continuous positive airway pressure (nCPAP): This device
clothed adult provides breathing support by gently pushing air into the baby's
lungs through prongs placed in the nose.
◦ Overbundling should be avoided
2. Intrauterine growth restriction happens when the unborn
◦ Infant should not feel hot to touch baby doesn’t get the nutrients and oxygen needed to grow and
develop organs and tissues.
AAP - Recommendations
3. C-Reactive Protein (CRP): This is a laboratory test that measures a
8. Avoid commercial devices marketed to reduce the risk of SIDS protein that is a non-specific marker for inflammation and therefore
infection.
◦ None have been tested sufficiently to show efficacy or safety
4. Inhaled nitric oxide is a pulmonary vasodilator that has a role in
◦ AAP - Recommendations
pulmonary hypertension and PPHN
9. Do not use home monitors as a strategy to reduce SIDS
5. Echocardiography (ECG): ECG is an important tool to assess heart
◦ No evidence that they decrease the incidence of SIDS function and help screen for signs of PPHN

AAP - Recommendations 6. Vernix caseosa is the white, cream cheese–like substance that
serves as a skin lubricant in utero.
10. Avoid development of positional plagiocephaly
7. Moderately preterm, born between 32 and 34 weeks of
◦ Encourage “tummy time”* pregnancy.

◦ infant is awake and observed 8. chest X-rays show how well the lungs and heart are working. X-
rays are used to diagnose most types of newborn breathing
◦ Encourage upright “cuddle time” conditions.
◦ Avoid excess time in car-seat carriers and “bouncers” 9. A ventilator is a machine that takes over the work of breathing and
is a form of life support.
◦ Alter supine head position during sleep
10. Echocardiography (ECG): ECG is an important tool to assess heart
*also enhances motor development
function and help screen for signs of PPHN and right ventricular
AAP - Recommendations dysfunction. It also helps identify the cardiac anatomy and evaluate
for any cardiac level right to left shunting.
11. Continue the Back to Sleep campaign
QUIZ 9
◦ Public education should be intensified
1. __________________This device provides breathing support by
◦ Secondary care-givers gently pushing air into the baby's lungs through prongs placed in the
nose.
◦ Child care providers

◦ Grandparents
2. __________________happens when the unborn baby doesn’t get
the nutrients and oxygen needed to grow and develop organs and
tissues.

3. __________________This is a laboratory test that measures a

protein that is a non-specific marker for inflammation and therefore
infection.

4. __________________is a pulmonary vasodilator that has a role in

pulmonary hypertension and PPHN

5. _________________is an important tool to assess heart function

and help screen for signs of PPHN

6. _____________is the white, cream cheese–like substance that

serves as a skin lubricant in utero.

7. ____________preterm, born between 32 and 34 weeks of

pregnancy.

8. ______________are used to diagnose most types of newborn

breathing conditions.

9. A ___________ is a machine that takes over the work of breathing

and is a form of life support.

10. ________________is a tool that helps identify cardiac anatomy

and evaluate for any cardiac level right to left shunting.