Congential varicella syndrome (CVS) and Neonatal infection

Etiology:

Mother contraction of Varicella zoster virus (chicken pox) during the first two trimesters of pregnancy.

Symptoms (in X % of cases):

skin lesions in dermatomal distribution (76%)

neurologic defects (60%)

eye diseases (51%)

skeletal anomalies (49%)

Prognosis:

• 30% of infants born with these lesions died in the first months of life.

Prevention:

Vaccination of women of child-bearing years who do not already possess immunity to the virus.

Neonatal Varicella zoster

Treatment and Management:

1. Acyclovir
2. Zoster immunoglobulins

Breastmilk Collection and Storage

Indications for breastmilk expression and collection:

1. To collect milk for an infant unable to suckle eg. premature infant
2. Relief of engorgement
3. To collect for duration when mother is unable to breastfeed eg. contraindicated post-medical procedure or when returning to work
4. To stimulate and increase milk production volume
5. To empty breasts if infant is unable to suckle properly

Criteria for choosing a breast pump:

1. Efficiently drains the breast
2. Intermittent vacuum suction cycle (prevents tissue trauma)
3. Ease of use
4. Easy to clean
5. Comfortable to use
6. Available spare parts
7. portable

Breastmilk Storage Criteria

1. Milk out at room temperature: use within 4 hours
2. Refrigerator: store and use within 48hrs
3. Self-defrosting freezer: use within 2-3 months
4. Deep-freezer: Use within 6 mo

• Date all containers.

Methods for defrosting milk:

1. Under running water
2. In fridge, to be used with 24 hrs

Caution for breastmilk defrosting:

1. Do not refreeze previously frozen milk
2. Do not defrost in microwave as this destroys nutrient and immunologic components

Breastfeeding and determination of adequate nutrition intake

There are several factors to gauge the infant is receiving adequate breastmilk intake to meet its metabolic and growth demands.

1. Number of bowel movements
2. Number of wet diapers daily: 6-8
3. weight gain
4. mood: contentedness between feeding periods
5. frequent feedings are normal: 8-12 feedings/24hrs

Breast Milk (Continued)

Breast milk Functions:

1. Nutrition
2. Affects biochemistry
3. provides passive immunity
4. destroys pathogens

Benefits of Breast milk of infant thymus development

• Thymus plays a role in immune system development
• The thymus is the location of T-cell differentiation and maturation
• At 4 months of age the thymus of exclusively breastfed infants is double the size of exclusively formula fed infants.

Breast Assessment of the Lactating Mother

Inspection

• Size, symmetry and shape have little bearing on breastfeeding ability
• hypoplasic breast tissue combined with large distance between breast is correlated with insufficient lactation
• Skin of the breast should be inspected for any abormalities
• Skin turgor and elasticity can be assessed by gently pinching the skin
• assess for lateral inscision scars made during breast augmantation or reduction surgery
• an incision in the vicinity of the cutaneous branch of the fourth intercostal nerve (5 oclock position on the left breast and 7 ocolock position of the right breast) may nerve dysfunction of this nerve path innervating the areola and nipple and hinder lactation
• Assess for areas of skin thickening or dimpling of breast or nipple, this could be signs of neoplasia
• Assess hormonal changes and breast tissue response to these changes with questions such as `Have your breasts grown during pregnancy` and `Have you experienced any tenderness or soreness`
• Nipple inversion should be assessed for and functional infant nursing assessment should be performed

Palpation

• wash hands prior to assessment
• assess nipple by compressing or palpating the areola between forefinger and thumb just behind the base of the nipple
• Nipple retraction inwardly when stimulated may be indicative of underlying connective tissue lesions

Health promotion and prevention of neonatal hyperbilirubinemia

Health promotion and prevention of hyperbilirubinemia

1. Promote and support successful breastfeeding
2. Establish protocols for the assessment of hyperbilirubinemia
3. Measure total serum bilirubinemia or trancutaneous bilirubinemia of jaundiced infants within 24hrs
4. Visual estimation of jaundice degree can lead to inaccurate assessment
5. Interpret labs results of hyperbilirubinemia with respect to infant’s age in hours old
6. Infants <38 weeks gestation, particularly those with inadequate milk intake in poor breastfeeding, those with congenital defects and infections such as hepatitis are at higher risk, requiring heightened monitoring.
7. Perform a systematic assessment on all infants before discharge for severe hyperbilirubinemia risk.
8. Educate parents to assess for newborn jaundice
9. Provide follow-up and home visits for those at higher risk
10. Treat newborns with severe hyperbilirubinemia with phototherapy and or exchange blood transfusion.

Source:

American Academy of Pediatrics, Clincical Practice Guideline, Subcommittee on Hyperbilirubinemai. (2004). Management of Hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 114 (1) 297-316

Types of Jaundice

Rotor’s syndrome

A rare, relatively benign autosomal recessive bilirubin disorder of unknown origin.

Idiopathic conjugated hyperbilirubinemia.

Symptoms:

• Chronic jaundice without evidence of hemplysis.
• Attacks of intermittent epigastric discomfort and abdominal pain may occur but are rare.
• There may be episodic fever.

Neonatal jaundice

A condition which is common 2-5 days after birth.

Etiology:

Bilirubin is a yellow pigment that is created in the body during the normal recycling of old red blood cells. Bilirubin is released due to the breakdown of heme in red blood cells. The liver takes up the byproducts of this break down and excretes them as bile, they are then removed from the body in the stool. If this old red blood cell breakdown occurs more quickly than the excretion of the byproducts the byproducts build up in tissues. This build up of the yellow bilirubin pigment in the tissues is called jaundice.

Neonatal jaundice is the results of abnormally high bilirubin levels, > 85 umol/l (5 mg/dL) manifests clinical jaundice in neonates.

Symptoms:

• The excess bilirubin pigments build up in the tissues manifesting as yellow tinged skin and sclera of the eye.
• jaundice typically first appears in the face then progresses caudally to trunk and extremities.

Conditions that increase the number of red blood cells that need to be broken down, and can cause more severe newborn jaundice:

• Abnormal blood cell shapes
• Blood type mismatch between the mother and the baby
• Bleeding underneath the scalp (cephalohematoma) caused by a difficult delivery
• Higher levels of red blood cells, which is more common in small-for-gestational-age babies and some twins
• Infection
• Lack (deficiency) of certain important enzymes

Conditions that make it harder for the baby’s body to remove bilirubin may also lead to more severe jaundice:

• Certain medications
• Congenital infections, such as rubella, syphilis, and others
• Diseases that affect the liver or biliary tract, such as cystic fibrosis or hepatitis
• Hypoxia
• Infections (such as sepsis)
• Many different genetic or inherited disorders

Assessment:

• every 8-12hrs
• perform assessment in well lit room
• blanch skin with digit pressure to reveal underlying tissue colour
• TSB levels should be performed on every janundiced infant within the first 24hrs after birth
• take Total Serum Bilirubin (TSB) levels to ensure levels remain <15mg/dL

Treatment:

1. Phototherapy: will be used if the bilirubin level is too high or is rising quickly. Blue light phototherapy acts to break down bilirubin in the skin. Phototherapy is initiated if TSB >25mg/dL.
2. Blood transfusion: Used in the treatment of the most severe cases of jaundice. An exchange blood transfusion will be used.
3. Intravenous immunoglobulin: another very effective method of reducing bilirubin levels.  Gamma globulins is used to treat cases of isoimmune hemolytic disease (due to fetal-maternal blood type incompatibility and ABO and Rh hemolytic disease of the newborn).

Mastitis (non-infected and infected)

Mastitis

Etiology:

blocked duct with inflammation

Symptoms:

• hard lump

• tender to touch

• redness and swelling as milk enters surrounding tissues

• discharge as increased pressure on surrounding ducts

Treatment and Management: (same as for plugged duct)

• frequent feedings on affected side

• moist heat application

• massage of affected area prior to, and during feedings

• point infant’s chin towards affected area during feeding to facilitate passage of blockage

• alternate infant feeding position during feeding to facilitate effective drainage

• prevent constriction of affected area by tight clothing

Infective mastitis

Etiology:

• Staphylococcus aureus infection of duct

• may follow blocked duct or mastitis

Symptoms:

• hardness

• reddened, tender area

• flu-like symptoms

• elevated temperature (>38.5 C)

• chills and headache

Treatment and Management

• antibiotics

• pain management as needed to manage breast discomfort

• antipyretics to manage fever

• continue breastfeeding to facilitate clearing of blocked duct and flushing of area

• moist heat compresses