Maternity - Newborn, part 4: NAS, Hypoglycemia, Macrosomia, Sepsis Neonatorum, Necrotizing Enterocolitis
by Meris Shuwarger BSN, RN, CEN, TCRN November 23, 2021 Updated: June 16, 2022 9 min read
Hi, I'm Meris with Level Up RN. And in this video, I'm going to be talking to you about some complications in the newborn, including things like neonatal abstinence syndrome, hypoglycemia, macrosomic infants, sepsis neonatorum, and necrotizing enterocolitis. So I'm going to be following along using our maternity flashcards. These are available on our website, leveluprn.com, if you want to grab a set for yourself. And if you already have a set, I would invite you to follow along with me. So let's go ahead and get started.
So first up, we are talking about neonatal abstinence syndrome. This is going to be the experience of the newborn who was exposed to drugs in utero. So this is going to be specifically related to opioids. However, it can be from other drugs as well. So just like an adult, if you are exposed to drugs over and over daily and then suddenly stop being exposed to them, you will go through withdrawal. And so will the newborn. However, in this instance, we call it neonatal abstinence syndrome. And remember that this is multi-system as well. So big signs and symptoms here are going to be a high-pitched or a shrill cry. That's going to be a red flag that something is not right with this infant. And specifically, this is going to be related to neonatal abstinence syndrome. Tremors, shaking, or convulsions, which are bigger shaking, fever, tachypnea, diaphoresis, irritability, poor feeding, diarrhea, constant sucking - that's going to be like a soothing mechanism - or increased muscle tone-- all of these are signs and symptoms. Remember that we want newborns to have strong muscle tone. But if they're really rigid, that could be a sign as well.
So treatment is going to be-- a lot of it is going to be supportive care, giving lots of skin-to-skin contact, reducing stimuli in the environment, that sort of thing. However, we can also treat the actual cause of the issue itself by replacing whatever substance it is that they work with, drawing from in small amounts of medically appropriate forms of that substance. So, for instance, morphine sulfate can be given buprenorphine methadone. We can also give anticonvulsants if they are having seizures or convulsions, right? Now, seizure precautions should be implemented, of course. And then we want to increase the number of feedings that they are giving so that they're getting the frequent feedings, but that they're going to be smaller feedings with high calories. We should also perform the Finnegan neonatal abstinence screening every three hours. So every three hours, we would go in and assess the baby. And we're going to look at them. And there's a scale where we assign points to them. The points or the change in the points from last time could alert us that, "Hey, things are getting worse. Maybe it's time to go on to actually treating them with morphine or something along those lines." Of course, we should also refer mom to substance abuse or drug and alcohol abuse treatment centers within reason. Of course, we can make those referrals. It doesn't necessarily mean that the patient will go or will be interested in those referrals. Referrals to child protective services, that's going to be dependent upon your state and rules and regulations. But a referral may need to be made as well for the fact that there was drug use in pregnancy.
There is something that I do want to mention, which is that neonatal abstinence syndrome is going to occur even if the drug is legally prescribed and prescribed by a physician who is aware of everything. If you have a patient who has a chronic illness or chronic pain problems and they're receiving those opioids, it may be something where a risk-benefit analysis is made and said, "This is better to proceed throughout pregnancy, taking these medications." The baby may still go through through abstinence, right? That may still happen. So this is not just for illicit substances. And so we should avoid assigning morality to this. This does not mean that you are a bad parent. This does not mean that you are abusive. This means that maybe we need to give you more support or something along those lines. But remember, we are always being therapeutic, compassionate, and understanding.
Now, talking about hypoglycemia. Hypoglycemia is defined here as a serum glucose less than 40 milligrams per deciliter within the first 4 hours of life - so 40 is the cutoff for four hours of life - or less than 45 milligrams per deciliter in 4 to 24 hours of life. So slight difference there. It is important to understand the difference however. So preterm or postmature infants, both at risk for hypoglycemia. An infant born to a mom who had gestational diabetes or who has diabetes just as their permanent state of being, that would also be a risk factor for infant hypoglycemia. Now, poor feeding is going to be a sign of symptoms. And it's also going to be a cause, right? Jitteriness and a weak cry. So we're just talking about neonatal abstinence, a high-pitched shrill cry. Hypoglycemia, this baby barely has the energy to even cry. They're going to have a weak cry. That's how I remember it, right? They may have a flaccid muscle tone. Again, we don't even have that glucose to have good muscle tone. They could have seizures. And then think also about just hypoglycemia in general. Diaphoresis, sweating is possible as well as cyanosis and apnea. Sweating in a newborn is never a good sign, right? We don't like a diaphoretic newborn. That is abnormal.
So treatment. Early breastfeeding if mom is breastfeeding. That is going to help to boost those glucose levels. And formula supplementation may be required. Maybe we are not producing enough milk. Or maybe we have insufficient glandular tissue. Dextrose gel. If the hypoglycemic gets severe enough, we may have to actually give this infant dextrose gel or IV glucose. Those are going to be similar to treatments for an adult with hypoglycemia, right? And the nursing care, we want to provide frequent feedings for this infant. So that might be reminding mom, "It's time to feed." Or this could be formula feeding as well. And then we want to monitor those blood glucose levels with a heel stick so that we can make sure that we are staying in a good range.
Now, kind of related, we're going to talk about macrosomic infant-- macro meaning large, soma meaning body. So this is an infant who is large for gestational age. They are above the 90th percentile. Or we can also say this is an infant larger than 4,000 grams in weight. That is a macrosomic infant. Risk factors for being macrosomic would be maternal diabetes. Remember, they're getting a lot of sugar from mom because of poor glucose control in diabetes. So more sugar means more weight. Postmature infant. So if the baby were not born until after 42 weeks, they're just going to be bigger, right? They don't stop growing. So that's going to be one thing there. Maternal obesity and then just genetics. Some people just have really big babies, right?
Complications though, if I have a really big infant, what are some complications related to birth? Birth trauma, right? I can have birth injuries, specifically shoulder dystocia, which we talked about in a previous video. But that is a big risk factor here. It's a big baby. The size of the birth canal does not change. The size of the baby does. Now, it's a really big baby coming through a static-size birth canal, right? Now, respiratory distress is possible. But the other one that I really, really, really want to call your attention to is hypoglycemia. Why does the macrosomic infant suddenly become at risk for hypoglycemia? Well, think about the fact that they were getting all of that sugar, all of that nutrition from mom. Their bodies are really used to getting that constant supply of sugar, right? And now, we have literally cut the cord. I am on my own here, and I am not getting that constant sugar. My body still expects it, right? It's still going to try and regulate all of my metabolic functions based on the idea that I'm going to be getting all this sugar, but I'm not. So that is why I am at risk for hypoglycemia as a macrosomic infant. So this is why if I see a macrosomic infant, I should think, "I need to check that baby's sugar frequently," right? Even if mom was not a gestational diabetic. Even if I'm still thinking this baby was getting a lot of nutrition to be so big, I need to make sure that the infant is adjusting to regulating its own metabolic functions okay. So early and frequent blood glucose testing is going to be very important for these children.
Now, sepsis neonatorum. This is going to be an infection in the bloodstream of an infant who is less than 28 days old. This is a really big cause of neonatal morbidity and mortality. So this is scary. You don't have a fully functioning immune system in those first few weeks of life. It takes time for your immune system to kick in because remember, I was relying on mom's immune system for a long time. So in those first four weeks of life, I'm incredibly at risk for infection. And I need to be-- as a parent, I need to be educated that a fever in a child of that age is a significant finding that requires further evaluation, right? So lots of risk factors here. Prematurity, low birth weight, chorioamnionitis-- that is an infection of the chorion and the amnion of the mom and baby. If I'm exposed to infection in utero, I could get sepsis as a newborn. Prolonged rupture of membranes. Remember those membranes, that amniotic sac was protecting me in utero. If we have prolonged rupture of membranes longer than 24 hours, we're at risk for infection. And now, I'm at risk for infection as a newborn.
Signs and symptoms. Poor feeding, irritability, lethargy, respiratory distress. Fever is the big one that I want to call your attention to. Hypothermia is also possible, though. So either high- or low-body temperature and hypotension. High- and low-body temperature is the same for adults with sepsis, right? Either a fever or hypothermia can indicate that I have sepsis. So that is not unusual. It does seem a little counterintuitive, but it is important to look for both extremes. Now, labs. A big one here is going to be positive blood culture. If I collect some blood, I culture it, and something grows, that is abnormal. Nothing should grow from my blood. There should be no bacteria in my blood. So that's going to be the biggest one here. But also hyper or hypoglycemia, acidosis, and an elevated CRP. CRP is a C-reactive protein. It's an inflammatory marker. So if it's elevated, that's always abnormal. But in this instance, for an infant, that should make you think sepsis.
Treatment is going to be IV antibiotics. We've got to get in there early. And we got to get in there fast with some strong antibiotics to knock out whatever is in there. And then the other thing is, remember, we need to collect cultures before we administer antibiotics. It is important that we do that because the second we administer antibiotics in the bloodstream, they're circulating everywhere. So even if I give the antibiotics and then culture the blood immediately, 15 seconds later, some of that antibiotic is in there. And it could inhibit growth and give us false negative blood cultures. So be sure to get cultures before administering antibiotics all the time in any sort of patient.
Lastly, we're going to be talking about necrotizing enterocolitis. This is a life-threatening inflammation of the intestines, and it can lead to necrosis. So necrotizing enterocolitis. Enterocolitis is inflammation of the small intestine and colon, and necrotizing referring to necrosis or death of that tissue. So risk factors here: prematurity, low-birth weight, hypoxia, which can be related to a congenital heart defect. Hypoxia. I'm not getting enough oxygen to all of my tissues, and then I can end up with this necrosis, right? So signs and symptoms. As with everything in an infant, poor feeding, lethargy, vomiting, and abdominal distension. Abdominal distension is going to be a big sign. Infants have these little pot bellies, right, but they should be soft and non-tender. A distended belly is going to be harder and kind of more swollen in appearance.
So treatment. We would do nothing by mouth. NPO status. We would put down an NG tube or an OG tube. Instead, we would give them total parenteral nutrition. So we are not giving any sort of feeds through the GI tract. Instead, all nutrition is going to be going through the vasculature. So we're going to be giving it directly to the bloodstream. Broad spectrum IV antibiotics to treat that infection and that inflammation. Bowel resection surgery may be indicated if we have a worsening condition or a perforated bowel. So complications here would be bowel perforation, peritonitis, sepsis, and death. So this is life threatening. This is something that we have to intervene in order to save this infant's life.
I hope that review was helpful. I'm going to give you some quiz questions to test your knowledge of some key facts I provided you. So let me know in the comments how you do, okay? So first up, the first question that I have for you is how frequently should we perform the Finnegan neonatal abstinence syndrome screening? How frequently should it be done? Secondly, I want to know what type of cry should the nurse expect to hear from a newborn with hypoglycemia? So what sort of cry would I hear in a hypoglycemic newborn? Third, I'm going to ask you what blood glucose level would indicate hypoglycemia in a newborn who is 18-hours old? 18 hours. That's an important part of that question. And lastly, name two complications-- I gave you a bunch of complications. But name two complications that a macrosomic infant may experience. Let me know how you did. Thanks so much. And happy studying.
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