Question

Client Profile Baby Martin was born via a normal spontaneous vaginal delivery (NSVD) at 36 weeks gestation. The mother arrived at the emergency room dilated to 9 centimeters and 100 % effaced. The mother also reports ruptured membranes for the past 22 hours. The fetal heart rate upon admittance to the emergency room is 170 bpm. The mother delivered in the emergency room 30 minutes after being examined. This is her seventh pregnancy, and she did not have prenatal care. Case Study Martin was admitted to the observation nursery from the emergency room where he was born. He weighed 5 pounds and was 19 inches long. His APGAR scores were 6 at one minute, and 8 at five minutes. Points were initially taken off for tone, reflexes, and color. His initial glucose was 35 and vital signs were heart rate 150, respirations 76, and temperature 97.2. The nurse noted some nasal flaring, grunting, and coarse breath sounds. He was given 1 ounce of D5W orally; oxygen therapy, and his skin and pharynx were cultured. The orders also included that he be placed on a warmer with skin probe for temperature monitoring. At two hours the baby's glucose was 40, the nasal flaring continued, respiratory rate was 100 with continued coarse breath sounds. He exhibited acrocyanosis, and his temperature was 96.8. The baby was treated for transient tachypnea of the newborn with oxygen therapy and a warm environment. At four hours the nurse noted that the baby was lethargic and difficult to arouse. He appeared pale with circumoral cyanosis, nasal flaring, and grunting with sternal retractions. The nurse notified the doctor, an IV was started, and the baby was transferred to the neonatal intensive care unit at a hospital in the next town. At six hours the mother called the NICU to check on his progress and was told that he had subsequently developed jaundice and was on a ventilator.

Questions (if you use sources please cite it)

1. Why is this baby hypothermic, and how does it affect this baby's transition? ( Please explain in detail)

2. . What is the significance of jaundice in a 6- hour old infant? ( please explain in detail )

3. How significant is the acrocyanosis? (please explain in detail)

Answer 1

QUESTIONS AND ANSWERS

1. Why is this baby hypothermic, and how does it affect this baby's transition? ( Please explain in detail)

• In premature infants, hypothermia increases morbidity and mortality. Hypothermia may be purely environmental or represent intercurrent illness (eg, sepsis). Maintaining an appropriate environmental temperature in the delivery room or operating room is critical in preventing neonatal hypothermia. Hypothermic infants should be rewarmed, and any underlying condition must be diagnosed and treated.
• Hypothermia may be caused by environmental factors, disorders that impair thermoregulation (eg, sepsis, intracranial hemorrhage, drug withdrawal), or a combination. Risk factors for hypothermia include delivery in an area with an environmental temperature below the recommended levels, maternal hypertension, cesarean delivery, and low Apgar scores.
• Thermal equilibrium is affected by relative humidity, air flow, direct contact with cool surfaces, proximity to cool objects, and ambient air temperature. Neonates are prone to rapid heat loss and consequent hypothermia because of a high surface area to volume ratio, which is even higher in low-birth-weight neonates. There are several mechanisms for heat loss:

•Radiant heat loss: Bare skin is exposed to an environment containing objects of cooler temperature.

•Evaporative heat loss: Neonates are wet with amniotic fluid.

•Conductive heat loss: Neonates are placed in contact with a cool surface or object.

•Convective heat loss: A flow of cooler ambient air carries heat away from the neonate.

• Prolonged, unrecognized cold stress may divert calories to produce heat, impairing growth. Neonates have a metabolic response to cooling that involves chemical (nonshivering) thermogenesis by sympathetic nerve discharge of norepinephrine in the brown fat. This specialized tissue of the neonate, located in the nape of the neck, between the scapulae, and around the kidneys and adrenals, responds by lipolysis followed by oxidation or re-esterification of the fatty acids that are released. These reactions produce heat locally, and a rich blood supply to the brown fat helps transfer this heat to the rest of the neonate’s body. This reaction increases the metabolic rate and oxygen consumption 2- to 3-fold. Thus, in neonates with respiratory insufficiency (eg, the preterm infant with respiratory distress syndrome), cold stress may also result in tissue hypoxia and neurologic damage. Activation of glycogen stores can cause transient hyperglycemia. Persistent hypothermia can result in hypoglycemia and metabolic acidosis and increases the risk of late-onset sepsis and mortality.
• Despite their compensatory mechanisms, neonates, particularly low-birth-weight infants, have limited capacity to thermoregulate and are prone to decreased core temperature. Even before temperature decreases, cold stress occurs when heat loss requires an increase in metabolic heat production.
• The neutral thermal environment (thermoneutrality) is the optimal temperature zone for neonates; it is defined as the environmental temperature at which metabolic demands (and thus caloric expenditure) to maintain body temperature in the normal range (36.5 to 37.5° C rectal) are lowest. The specific environmental temperature required to maintain thermoneutrality depends on whether the neonate is wet (eg, after delivery or a bath) or clothed, its weight, its gestational age, and its age in hours and days.

2. What is the significance of jaundice in a 6- hour old infant? ( please explain in detail )

• Jaundice is very common in newborn babies. It is usually easy to spot because the baby’s skin and whites of the eyes turn a yellow colour. Babies become jaundiced when they have too much bilirubin in their blood.
• Bilirubin is a normal pigment made when red blood cells break down in the body. It is usually processed by the liver, recycled and eliminated in the baby’s stool. When a baby has jaundice, it means either his body is making too much bilirubin or the liver is not getting rid of it quickly enough.
• Feeding (especially breastfeeding) your baby often in the first hours and days after birth helps reduce the risk of jaundice. Your baby will pass more stool, and the milk gives your baby’s liver the energy it needs to process the bilirubin.
• Most jaundice is not harmful to your baby. It usually shows up during the baby’s first 3 to 5 days of life. Then it disappears as the baby’s body learns to deal with bilirubin.
• In some situations, however, there is so much bilirubin in a baby’s blood that it can be harmful. If the level of bilirubin becomes very high, it may affect some of the baby’s brain cells. This may cause the baby to be less active. In rare cases, a baby may develop seizures (convulsions). The effects of this kind of jaundice may also lead to deafness, cerebral palsy and/or mental retardation. Fortunately, it can usually be prevented.
• Jaundice can cause problems for some babies, including:

· Preterm babies born before 37 weeks’ gestation;

· Babies who weigh less than 2500 g at birth;

· Babies whose blood group is incompatible with their mothers’ blood group;

· Babies who develop jaundice early in life, especially during the first 24 h;

· Babies whose jaundice has moved into the arms and legs;

· Babies who have an infection;

· Babies who have bruises and a difficult delivery (for example, where forceps have to be used); and

· Babies whose siblings had jaundice at birth and needed treatment.

3. How significant is the Acrocyanosis? (please explain in detail)

• Acrocyanosis refers to cyanosis found in the extremities, particularly the palms of the hands and the soles of the feet. It can also be seen on the skin around the lips.
• Acrocyanosis is common in newborns.Acrocyanosis is often normal in babies, as long as no cyanosis is present in the central part of the body.
• Children may have acrocyanosis when they are cold (such as swimming in cold water) but it should resolve once they are warmed up.
• Acrocyanosis can be associated though with poor perfusion, and if this finding persists, may require further evaluation and treatment.
• The transition of the newborn to room air involves multiple changes physiologically leading to expansion of the chest wall and lungs.
• There is increased negative intrathoracic pressure upon delivery, followed by a decrease in the pulmonary vascular resistance (PVR). If the PVR is high, blood shunts though a patent ductus arteriosus (PDA), for 48 hours or more. In a normal neonate, the PDA has physiologic closure by 48 hours and anatomic closure within two to three weeks
• Acrocyanosis is a painless condition where the small blood vessels in skin constrict, turning the color of hands and feet bluish. The blue color comes from the decrease in blood flow and oxygen moving through the narrowed vessels to extremities.
• There are two types of acrocyanosis, primary and secondary:
  • Primary acrocyanosis is associated with cold temperature and emotional stress. It’s not considered harmful.
  • Secondary acrocyanosis is associated with many different underlying diseases, including eating disorders, psychiatric illnesses, and cancer.
• The cause of acrocyanosis in newborns is attributed to the infant getting used to the change in blood circulation from the womb. Oxygen-rich blood initially circulates to the brain and other organs rather than to the hands and feet.