Archive | April 2011

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