Common Skin Conditions

Normal color for Caucasian babies is pink. African-American babies may appear Caucasion-look at their scrotum & nipples, they will be darker in color.  Babies will get pigment later, around 2 months.

Vernix Caseosa- cheesy/white substance, more on premies than on full term, very little on post term babies

-protects fetus against effects of amniotic fluid in utero(dries skin & may cause peeling/cracking, shiny skin) (this is why post term babies have shiny/peeling skin)

            -serves in newborn as an insulating agent & protects against heat loss

Lanugo- fine hair which appears at 20 wks, usually gone by birth except around shoulders/face, preterm babies have more

Milia- distended sebaceous glands, white papules on cheeks, forehead, nose, no treatment needed, will disappear

Mongolian Spots- deep bluish pigment in deep layers of skin around sacral & gluteal areas; frequent in Asians, African-Americans & other dark-skinned (Greek, Latino), no treatment needed, disappears about 4 years

Erythema Toxicum- newborn rash, could occur anywhere, no pruritis (itching) associated, transient, no tx

Port Wine Stain- capillary hemangioma; birthmark, large, can be on face, permanent, removed by laser

Acrocyanosis- immature peripheral circulation, causes blue hands & feet in the 1^st 24 hrs after birth

Nursing care of the Newborn in the Delivery Room

-VS taken, axillary temp

-Apgar scoring, done at 1 & 5 min after birth, rare to get a 10

-Weight -taken daily because baby will lose 10% of body wt in 1^st 3-4 days d/t loss of ECF & meconium (black tarry 1^st still expected w/in 48 hours – some babies expel meconium in utero d/t stress, is a problem d/t ingesting meconium, baby will be suctioned & may require antibiotics)

            -birthweight is regained within 10-14 days

            -wt doubles at 6 months & triples at about 1 yr, quadruples @ 2 ½ years

-Height – crown to heels

-Cord care-cord is clamped & cut

-Meds given- state law-

-Vit K- given in delivery room or in nursery after 1^st bath to prevent bleeding because their intestinal tract is sterile & doesn’t harbor the bacteria needed to synthesize Vit D -given in vastus lateralis because it’s the most developed muscle

            - Erythromycin Opthalmic Ointment – given to protect from blindness d/t gonorrhea, Chlamydia, syphilis, etc… (if mom has gonorrhea, baby is treated w/antibiotics)

-suction

-ID them, wrist & ankle

-general physical assessment

-footprints

-gestational age

Nursing care of the Newborn in the Nursery

-physical assessment

-Neurological assessment-reflexes

-weight

-hearing screening- earphones placed on babies & brainwaves are monitored

-teaching

-circumcision-done day 2, if Jewish done day 8

-immunizations- Hep B in 0-2 days 1^st dose, other doses follow in subsequent months

- 1^st urine should be in 24 hrs, odorless & colorless

- 1^st stool in 48 hours

- will check babies for hypoglycemia to prevent brain damage that results from low blood sugar as fuel for the brain

-Screening Tests- Inborn Errors of Metabolism - group of hereditary disorders that are transmitted by a mutation in a gene which causes an enzyme defect which blocks a metabolic pathway; this leads to build-up of metabolites which are toxic to the newborn; state law requires these screenings; usually done on 2^nd day so that newborn has eaten & these disease processes can be seen:

- PKU – phenylketonuria – hepatic enzyme phenylalanine hydroxyalase which controls conversion of phenylalanine to tyrosine is absent resulting in build-up of phenylalanine in blood stream – if untreated will cause MR, controlled by diet – there is no cure – baby will eat formula called Lofenalac – if mom wants to breastfeed she must really watch her diet – child must stay on this diet until 10 y/o when brain is 95% developed – found in 1 in 13,000 live births; no cure

- MSUD – maple syrup urine disease – urine smells like maple syrup, found in amish population, 1 in 70,000 live births – defect in the breakdown of amino acids/protein, controlled by diet, untreated it results in Failure to Thrive, neurological complications & death; no cure

- Congenital Hypothyroidism – 1 in 3,600-5,000 live births, may result from failure of thyroid gland to develop (thyroid is first gland to develop, usually at wk 4) or the gland is not secreting enough thyroxine, untreated it results in respiratory, feeding, & growth problems & MR; is treated w/medication

- Galactosemia – 1 in 45,000 live births; inability to convert galactose to glucose, treated by diet, avoid milk products, babies given soy based formula (Prosobee or Isomil), mom can breast feed but mom must watch her diet; untreated can lead to cataract formation, liver or kidney disease, MR; this is NOT the same as lactose intolerance!

            - Sickle Cell Anemia

- G6PD – inability of blood to protect the hemoglobin molecule, results in anemia, jaundice; treated w/diet

-bath

-noting 1^st stool & urine:

-1^st stool = meconium (black, tarry), occurs in 48 hrs, breastfeeding also helps facilitate 1^st stool; meconium forms in the intestines 13-16^th wk of gestation

-1^st urine = is colorless, odorless, and should happen w/in 24 hrs

Newborn Nutrition

Breast feeding:  Colustrum – yellowish, days 1-3, facilitates passage of meconium, then transitional milk, then around day 10 mature milk starts; breast feeding done on supply/demand basis – the more you feed the more is produced, most babies should be fed every 2 hours; milk ducts are in areola so baby must have whole areola in mouth to get proper feeding

Hormones:  Prolactin- responsible for milk production; Oxytocin – responsible for milk ejection (also speeds involution)

Advantages: immunity given from mom to newborn, cheaper, facilitates bonding, milk is correct temperature & nutrients, breast feeding helps prevent breast cancer in mom, mom is more likely to get back to pre-birth weight, facilitates quickening of Involution (uterus returns to pre-pregnant state), breastfeeding decreases mom’s risk of diabetes by 15% for 15 years after breastfeeding

Disadvantages: mom’s freedom is limited d/t frequent feedings

Bottle feeding:  most common type of feeding; formula’s very expensive & not nutritionally perfect

Newborn Sleep Requirements

- 16-18 hrs/day MAYBE

- Most of their sleep is spent in stages 3 & 4, deep sleep

- REM is almost 50%

- NREM is evident by regular respirations, no eye/body movements

Problems of the Newborn

Physiological Newborn Jaundice- most common type of jaundice

            -60% of full term babies & 80% of preemies develop it

            -between days 2-4 after birth

            -a symptom of a condition caused by functional immaturity of liver at birth

- in utero baby has excess RBC’s which once born are broken down into bilirubin & excreted via blood thru liver, but in this case, liver is not fully func; causing bilirubin to build up & cause yellow skin & sclera

-Tx- UV lights & sunlight: converts bilirubin from fat to water soluable for easy excretion

            -breaks down bili from fat soluble to water soluble so it can be excreted

            -normal bili levels: < 1 mg/100 ml   (takes 10 days to achieve)

            -fluids are encouraged for excretion

            -bili levels are monitored

            -sometimes nothing is done for 72 hours until liver is fully functioning

Pathological Jaundice  AKA  Hemolytic disease of the newborn

Rh factor:  Mom is Rh- , Dad is Rh+ , assuming that fetus is + (because dominant gene)

                        -if Mom is - & baby is +, blood may mix in-utero, causing built up antibodies which will fight the foreign bodies & cause destruction & anemia in the baby

                        -1st baby is NOT affected, takes time to build up antibodies, takes large mixing of blood which occurs normally during placental separation after the baby is born (so, can then test the baby & treat for 2^nd preg if needed)

                        -if 2^nd pregnancy & 1^st baby was Rh+, mom has already built up the antibodies, so is given RhoGAM to prevent the antibodies from fighting against the new fetus

                        -RhoGAM always given in 2 doses; 1- during 1^st preg @ 28 wks;

                        2- within 72 hrs after birth if that first baby was positive  (protecting NEXT pregnancy is the key)

                        -RhoGAM gives a small amount of antibodies to Mom which fools the immune system & clears the fetal RBC from maternal circulation, thus blocking antibody production

                        -Mom may also get RhoGAM after any invasive procedures during the pregnancy, this would be a 3^rd dose (or if mom has untypeable pregnancy: ectopic, abortion, miscarriage…)

Test= Direct Coombs- done on direct cord blood to see if it is coated w/maternal antibodies; a NEGATIVE result is desired meaning no antibodies prod

Other ways to test if 2^nd baby is affected:

1.   Indirect Coombs on Mom’s blood (aka antibody titer):  if +, means antibodies are in Mom’s system, the higher the titer, the more antibodies present

2.   Amniocentesis- checks the bili level in the amniotic fluid, the higher the bili level, the lower the fetal hemoglobin, meaning antibodies have begun to attack

3.   Percutaneous Umbilical Blood sample procedure:

a.   Done under ultrasound to locate placenta, fetus & cord

b.   Needle inserted via large vein into cord

c.   Fetus transfused w/small amt of negative blood so that fetus is able to absorb RBC into circulation by way of lymphatic veins and use RBC to counteract the anemia

d.   Procedure is done as needed from 20-25 wks until 34-35 wks, until baby is delivered by c-section

e.   This baby is born with Erythroblastosis Fetalis Condition

Baby is jaundice all over, has generalized edema (aka anasarca), progressive anemia, CNS involvement, cardiac failure, stillborn, may develop severe resp distress

      - If after 3 days, can’t get bili levels down may develop Kernicterus which is a severe brain damage, symptoms include: poor muscle tone, lethargy, poor sucking           & swallowing, followed by spasticity & convulsions; death occurs in 75% & remaining 25% will be mentally retarded, paralyzed, or will develop deafness

- Treatments: exchange blood transfusion; exchange baby blood for same amount of donor O negative   blood to decrease anemia caused by antibodies on baby’s blood

Also, phototherapy

****BUT, RhoGAM has prevented these conditions since 1968****