HIGH-RISK

NEWBORN-
IDENTIFICATION,
CLASSIFICATION AND
NURSING MANAGEMENT

SUBMITTED TO: SUBMITTED BY:

Mrs. Anitha Madam P. Sreemani
Lecturer M.Sc Nursing
Govt. College of Nursing 1st Year
Govt. College of Nursing
Name of the student : P. Sreemani
Name of the subject : Advanced Nursing
Practice
Topic : High-risk
Newborn-
identification,
Classification and
nursing management

Group : M.Sc Nursing 1st year

Medium of Instruction : English
Method of Presentation : Lecture cum
demonstration
Date of time :
Place : Govt. College of
Nursing Classroom
Duration : 10-15 mts
Name of the Supervisor : Mrs. Anitha Madam
INTRODUCTION
• The high-risk neonate is a newborn, regardless of gestational age or
birth weight, who has a greater- than-average chance of morbidity or
mortality because of conditions or circumstances superimposed on the
normal course of events associated with birth and the adjustment to
extra uterine existence.

DEFINITION
High risk newborn can be defined as a newborn regardless of birth
weight, size or gestational age who has a greater chance of morbidity
specially within the first 28 days of life.

HIGH RISK PERIOD

The high risk period encompasses human growth and development
from the time of viability up to 28 days following birth and includes
threats to life and health that occur during the prenatal, prenatal, and
postnatal periods.

CLASSIFICATION OF HIGH RISK NEW BORN

1. According to size
According to Mortality
2. According to Gestational age
According to pathological Conditions

ACCORDING TO SIZE
1. Low birth weight

2. Very low birth weight

3. Extremely low birth weight

4. Appropriate for gestational age

5. Small for date

6. Intrauterine growth restriction

7. Symmetric IUGR

8. Asymmetric IUGR

9. Large for gestational age

1) LOW-BIRTH-WEIGHT

(LBW) infant – A baby whose birth weight is less than 2.5 kg (2500
gm.), regardless of gestational age.

2) VERY-LOW-BIRTH-WEIGHT (VLBW)
infant -A baby whose birth weight Is less than 1500 gm.

3) EXTREMELY-LOW- BIRTH-WEIGHT (ELBW)

INFANT -A
baby whose birth weight is less than 1000 gms.

4) APPROPRIATE-FOR- GESTATIONAL-AGE (AGA)

infant -An infant whose birth weight falls between the 10th and 90th
percentiles on intrauterine growth curves. "Appropriate for gestational
age" refers to the level of growth and development appropriate for the
age of the fetus

-ADAM
CLASSIFIED AS LOW BIRTH WEIGHT BABIES.
1. Perinatal asphyxia

2.Hypoglycemia

3. Hypocalcemia

4. Aspiration syndrome

5. Increased heat loss

6. Feeding difficulties

7. Polycythemia

TREATMENT
a) Management at birth
b) Dry and wrap in warm blankets soon after birth
c) Supportive care
d) Nutritional support

NURSING INTERVENTIONS:
 Support respiration efforts, monitor respiratory status
closely for charges.
 Provide normal thermal environment
 Protection from infection
 Provide appropriate nutrition.
 Keep in mind that SGA neonates have higher caloric
needs and benefit from frequent feedings
  Monitor blood glucose levels as ordered
 hypoglycemia is common due to reduced glycogen
stores
 IV glucose may be needed if blood glucose levels are
less than 40mg/dl
 Maintain adequate hydration Monitor intake and output
Administer IV fluid therapy as ordered Provide
meticulous skin care

CLASSIFICATION OF HIGH RISK NEW BORN

ACCORDING TO SIZE

Small-for-dates (SFD) or small-for-gestational-age (SGA) infant-An

infantwhose rate of intrauterine growth was slowed and whose birth
weight falls below the 10th percentile on intrauterine growth curves.
CLASSIFICATION OF HIGH RISK NEW BORN ACCORDING
TO SIZE

6) Intrauterine growth retardation (IUGR)- Babies who do not grow

adequately in utero.
7) Symmetric IUGR
8) Asymmetric IUGR
SMALL FOR GESTATIONAL AGE:
The term is to designate the newborn with birth weight less than the
10th percentile on intrauterine growth chart is called small for
gestational age. It is also referred to as small for date and intrauterine
growth retardation (to as small date and). A fetus of SGA may be
constitutionally small or due to a pathologic process (fetal growth
restrictions).

ASSESMENT FINDINGS
✓ Wide-eyed look.

✓ Sunken abdomen
✓ Loose, dry skin

✓Decreased chest and abdomen circumstances

✓Decreased subcutaneous fat

✓ Thin, dry umbilical cord

✓ Sparse scalp hair

CAUSES:
The underlying problem is intrauterine growth retardation.

MATERNAL CONDITIONS
a) Poor nutrition
b)Socioeconomic fetus
c) Purity and no. of fetus’s in utero
d) Advanced diabetes
e) Pregnancy induced hypertension
f) Smoking
g) Age older than 35
h) Drug abuse
i)Partial placental separation and malfunction Fetal conditions
a) Intrauterine infection
b) Chromosomal abnormalities and malfunctions

NEONATAL RISKS ASSOCIATED WITH SGA

8. Prenatal asphyxia
9. Hypoglycemia
10. Hypocalcemia
11. Aspiration syndrome
12. Increased heat loss
13. Feeding difficulties
14. Polycythemia

TREATMENT
 Management at birth
 Dry and wrap in warm blankets soon after birth
 Supportive care
 Nutritional support

NURSING INTERACTIONS
✓ Support respiration efforts, monitor respiratory status closely for
charges.
✓ Provide normal thermal environment

✓ Protection from infection

✓ Provide appropriate nutrition.

✓ Keep in mind that SGA neonates have higher caloric needs

and benefit fromfrequent feedings.

✓ Monitor blood glucose levels as ordered
✓ Hypoglycemia is common due to reduced glycogen stores.

✓ IV glucose may be needed if blood glucose levels are less

than 40mg/dl
✓ Maintain adequate hydration

✓ Monitor intake and output

✓ Administer IV fluid therapy as ordered

✓ Provide meticulous skin care

✓ Encourage parenteral interaction with neonate to promote

bonding
✓ Keep parents informed and provide support to the entire

family.

CLASSIFICATION OF HIGH RISK NEW BORN

ACCORDING TO SIZE
9) Large for gestational age (LGA) infant- an infant whose birth
weight falls above the 10th percentile.

SCALE-TRONIX PEDIATRIC CALE

ACCORDING TO GESTATIONAL AGE

• PRETERM

• Full term

• Late preterm

• Post term (post mature)

CLASSIFICATION ACCORDING TO GESTATIONAL

AGE
1) Premature (Preterm) infant- A baby born before completion of 37 th
weeks of gestation, regardless of birth weight.

2) Full term infant - an infant born between the beginning of the 38

weeks and completion of the 42 weeks of gestation, regardless of birth
weight.
3) Post term (post mature) infant – An infant born after 42 weeks of
gestational age, regardless of birth weight.

POST TERM NEWBORN CHARACTERISTICS

 Newborn emaciated
 dry peeling skin
 Meconium stained Creases cover soles
 Hair and nails long
 Limited vernix & lanug

4) Near-term (late- preterm) infant – An infant born between 34 and

36 weeks of gestation, regardless of birth weigh

PROBLEMS ASSOCIATED WITH PRE-TERM, TERM

AND GROWTH RETARDED BABIES RESPIRATORY
DISTRESS SYNDROME (HYALINE
MEMBRANEDISEASE)
• Respiratory distress syndrome is characterized by progressive
and frequently fetal respiratory disorder from atelectasis and
immaturity oflungs.

INCIDENCE
RDS is the most common cause neonatal mortality. In the US
alone, it causes death of 40,000 new borns every year.

CAUSES
Although the airways and alveoli of infant's respiratory system are
present by 27th gestation, the inter costal muscles are weak and the
alveoli and capillary blood supply is immature. In RDS, the premature
infants develops wide spread alveolar collapse because of lack of
surfactant.

SIGNS AND SYMPTOMS

1. May breathe normally at first.
2. Rapid, shallow respirations then prolonged respirations appear.
3. Intercostals, sub costal, sterna refractions.
4. Nasal flaming.
5. Audible expiratory grunting.
6. Frothy sputum.
7.Low body temperature.

TREATMENT
I. Vigorous respiratory support.
2. Warm, humidified, oxygen enriched gases are administered by
oxygen hood with the treatment of choice.
3. Mechanical ventilation.
4. Radiant infant warmer or isolette
5. Sodium bicarbonate i.v as necessary.
6. Tube feedings or hyper aliment.

NURSING INTERVENTION
1. Monitor arterial bloodgases (ABGS)
2. 2. Monitor per injection, thrombosis, or decreased circulation
to legs if the infant has an umbilical catheter.
3. 3. Take daily weights.
4. 4. Assess skin color.
5. 5. Monitor respiratory rate, depth and character as well as other
signs of distress.
6. 6. Provide parenteral teaching and emotional support,
encourage bonding.
CLASSIFICATION ACCORDING TO MORTALITY
 Live birth
 Fetal death
 Neonatal death
 Perinatal death
 HIV mortakity
1. Live birth: birth in which the neonate manifests any heart beat,
breathness or displays voluntary moment, regardless of
gestational age.
2. Fetal death: death of the fetus after 20 weeks of gestation and
before deliver with the absence of any signs o the death
3. Neonatal: death: Death that occursin the first 27 days of life,
wearly neonatal death occurs in the first week of life. Late
neonatal death occurs at 7 to 27 days.
4. Perinatal: death: Total no of fetal and early neonatal deaths per
1000 live births.
5. Neonatal mortality in HIV exposed infants: Death occos to
newborn HIV mothers

CLASSIFICATION ACCORDING TO PATH

PHYSIOLOGICAL CONDITIONS
1. Associated with the state of maturity of the infant
2. Chemical disturbances: e.g. Hypoglycemia, Hypocalcaemia
3. Immature organs and syatems: hyperbilirubinemia, respiratory
distress, hypothermia.

JUANDICE
Jaundice is the yellow discoloration of the skin caused by
accumulation of excess of bilirubin in the tissues and serum. Neonatal
jaundice becomes apparent at serum bilirubin concentration of 5-7
mg/dl. Jaundice shoulders and trunk indicates a level of 8-10 mg/dl.
Jaundice of the lower body appears at 10-12 mg/dl and entire body at
12-15 mg/dl.
TYPES:
1.physiolgical jaundice
2.Pathological jaundice

CAUSES OF PHYSIOLOGICAL JAUNDICE:

1) Increased Red cell breakdown Newborns have a shorter life
span( 100 days-term, 60-80) days preterm.
2) Decreased albumin binding capacity days preterm.
3) Enzymes deficiency
4) Increased enterohepatic re-absorption

MANAGEMENT:
1) Adequate feeding
2) Careful observation of newborns and serum bilirubin testing.
3) In premature babies, rising bilirubin level to critical level
require use of photography or phenobarbitone administration.

B) PATHOLOGICAL JAUNDICE:U:
usually appears within 24 hrs of birth and is charactertirized by a
rapid rise in serum bilirubin and prolonged jaundice.

FEATURES OF PATHOLOGICAL JAUNDICE:

1) Clinical jaundice appears within the first 24 hrs of life.
2) Increase in bilirubin >5mg/dl per day.
3) Total bilirubin >13mg/dl.
4) Persistance of clinical jaundice for 7-10 days in full term infants
and two in premature.
CAUSES OF PATHOLOGICAL JAUNDICE
1) Conditions that can lead to increased hemolysis
 Rh-ABO incompatibility
 Increased red blood cell fragibility
 Deficient red blood cell enzyme- glucose-6- Causes
of Pathological jaundice phosphate dehydrogenase
deficiency
 Neonatal sepsis - increased Hb breakdown
2) Defective conjugation
 Diminished production of enzyme glucoronyl transferase
 Immature liver calls as in premature infants
 Dehydration, sepsis, hypoxia
 Metabolic disorders

TREATMENT
Phototherapy

CLASSIFICATION ACCORDING TO
PATHOPHYSIOLOGY CONDITIONS
1. New born exposed to HIV/AIDS new born with congential
anomalities
Predisposing factors:
1. Pregnancy between the age of 15-19 years.
2. Multiple pregencys.
3. Hereditary

FACTORS TO DEFINE HIGH RISK INFANT:

a. Demographic social factors
 Maternal age
 Teenage marriage
  Physical stress
 Socio-economic status
b. Previous pregnancy
 Inteauterine deaths
 Neonatal deaths
 IUGR
 Congentinal malfunctions
c. Present pregnancy
 Vaginal bleeding
 PROM
 Multiple gestation
 Pre Eclampsia
 Abnormal USG findings
d. Labor and delivery
 Obstructed labour
 Fetal distress
 Forceps delivery
 Meconium stained liquor
e. Neonated
 Birth weight 4000
 Gestation 42 weeks SGA
 Respiratory distress
 Congential malformation

COMMON CAUSES:
 High risk related to immature preterm infants
 Post term infant causes
 Maternal infections
 Factors related to pregnancy
 Fetal factors
HIGH RISK RELATED TO IMMATURE PRETERM
INFANTS:
1. Etiology of preterm birth
2. Unknown maternal factors
3. Malnutrition
4. Chronic disease related to heart, renal, diabetes.

POST TERM CAUSE

1. Little if any vernix caseosa.
2. Abundant sclap hair.
3. Long finger nails.
4. Fetal distress associated with the decreasing efficiency of the
placents
5. Marcosomia
6. Meconium aspiration

MATERNAL INFECTIONS
1. T- Toxoplasmosis
2. O- other (hepatitis, measles, mumps, HIV)
3. R- Rubella
4. C- Cytomegalovirus infection
5. H- Herpes simplex-stop transmission, conjunction and
chylamydial conjunctivitis)

FACTORS RELATED TO PREGNANCY

1. Hypertention
2. Abriptio placenta or plan=centa previa
3. In competent cervix
4. Premature rupture of membrances
5. Choriominotitis
6. Polyhydramnios
FETAL FACTORS
1. Chromosomal abnormalities
2. Intrauterine infections
3. Anatomic abnormalities

CLINICAL SIGNS OF HIGH RISK NEWBORN

1) Heart rate.
 The infant may have a:
 Tachycardia (a heart rate more than 160 beats per minute)
 Bradycardia (a heart rate less than 120 beats per minute)
2) Respiration rate and pattern.
Abnormal signs are:
 Slow, shallow, irregular respiration
 Rapid respiration (tachypnea) more than 60 breaths per minute
 Grunting, recession or gasping
 Apnea Respiration
 Breathing in: diaphragm contracts Diaphragm
 Breathing out: Gapleages relaxes Rib pair positions during
inspiration and expinion
 Breathing in -Breathing out
3) Temperature.
The infant may be hypothermic (cold) or pyrexia (hot).
4) Activity.
The infant may be: Lethargic and respond poorly to stimulation
Hypotonic and less active than before Feeding poorly Jittery with
abnormal movements or fits BRF
5) Color.
 The infant may be
 Pale,
 Plethoric (very red),
 Cyanosed. & Centrally or peripherally, Severely jaundiced
 IDENTIFICATION AND CLASSIFICATION OF
NEONATAL INFECTONS,
OPHTHALMIANEONATORUM,
CONGENTALSYMPHILLIS AND HIV AND AIDS

INTRODUCTION
Infections of neonates during neonatal period called neonatal
infections. Neonatal infections are the most common of neonatal
mortality in India. Infections can occur in intrauterine life or during
delivery or in neonatal period. The neonates are more susceptible to
infections because they lack natural immunity and take some time for
development of acquired immunity.

DEFINITION OF NEONATAL INFECTIONS

Invasion and uncontrollable growth of pathogenic micro organisms in
the body of neonate is known as neonatal infections.

SOURCE OF INFECTIONS
Infections can occur in antenatal, intranatal and postnatal period due
to various conditions.

ANTENATAL PERIOD:
Antenatal infections may occur due to various micro organisms and
described with an acronym of STORCH

Where in:

S:Syphilis

T: Toxoplasmosis
O: Other(Gonococci infections, Tubercular infection, malaria,
varicella,hepatitis B, HIV Etc.)

R: Rubella

C: Cytomegalovirus and

H: Herpes simplex virus

These infrctions can develop due to direct transplacental transfer or

following plancentalinfectons.

INTRANATAL PERIOD
Aspiration oof infected liquor in prolonged Lbour following early
rupture of membrane which may lead to neonatal aspiration
pneumonia.

Infection may occur due to related vaignal examination by the

delivery assistant espically when the membrane is ruptured.

Infected birth passage may infect the eyes and mouth of the neonated
leading to opthalmianeonatorum and oral thrush.

Improper aspetic technique during care of umbilical cord may cause

umbilical sepsis.

Ascending infections with contaminated liquor amnii and amnionitis

related to infected birth passage and premature rapture of membrane
may also lead to intrauterine infections of the fetus.

POSTNATAL PERIOD
The following are important cause of neonatal inspections in postnatal
period.
  Transmission of infections from human contact or care giver
espically from infected hands of mother or family members and
health care providers.
 Cross infection from other baby who is infected and no barrier
nursing is practiced and universal precautions are not followed.
 Infected articles for baby care and contaminated clothing.
 Invasive procedures without asoetic technique.
 Infected environment around the neonated at hospital or home.

PREDISPOSING FACTORS RESPONSIBLE FOR

NEONATAL INFECTIONS
The predisposing factors of neonatal infections:

 Low birthweight infant

 Contaminate infrauterine environment like prolonged rapture of
membrane, unhygienic and multiple vaginal examinations,
meconium-stained liqupor Etc.
 Infected birh canal and infection at birth in deliver room or
neonatal care units.
 Birth asphyxia and resuscitations
 Congenital anomalies.
 Various procedure with inadequate asepsis during IV infusion,
parental medication, endo trachel intubation, assisted
ventilation, exchange blood transfusion Etc.
 Artificial feeding other than human milk.

CLASSIFICATION OF NEW BORN INFECTIONS

On the basis of source: The various types are

1. Intrauterine infections
 2. Perinatal infections
3. Early neonatal infections
4. Late-Onset neonatal infections
5. Post neonatal infections
Intrauterine infections:
It refers to infection acquires in utero. The STORCH a group of
infections( syphilis, toxoplasmosis, rubella, cytomegalovirus, herpes
simplex virus) belonging to this category. Viral infections in utero
may lead to fetal death, congenital malformation or severe systemic
manifestations of disease.

The presence of the any three of the following features should

make alert to the possibility of intrauterine infections.

a. maternal history of infections

b. intrauterine growth retardation
c. hepatosplenomegaly
d. jaundice
e. Meningo-encephalitis.
f. Raised.IgM in cord blood

Perinatal infections:
it refers to the infections that is acquired just before pregnancy and
during delivery from the mother. Such an infection occurs from the
organisms colonizing the birth passage.

Early neonatal infections:

Should be limited to perinatal infections wit h manifestations
occurring within 72hrs. of birth
Late-Onset neonatal infections:
It is sepsis occurring after 8th day of birth

Post neonatal infections:

it refers to the infection occurring after 28 days of delivery. The
organisms responsible for post natal infections are staphylococcus
areus, Klebsialle, proteus, E.Coil, salmonella pseudomonas, candida
albicans.

ON THE BASIS OF LOCATION :THE INFECTION

CAN BE SUPERFICIAL OR SYSTEMIC
1. Superficial infections
2. Systemic infections
Superficial infections: the infections occurs on the outer side of
body. The common sites of superficial infections are eye, skin,
umbilicus and oral cavity.

Systemic infections: it includes septicaemia, meningitis,

pneumonia, nercotisingenterocolitis, tetanus neonatorum, systematic
candidiasis, DIC( disseminated intravenous coagulopathy),
pyelonephyritis etc.

BASED ON THE CAUSATIVE ORGANISMS

1. bacterial infections
2. viral infections
3. protozoa infections
4. fungal infections
 NEONATAL CONJUNCTIVITIS( POTHALMIA
NEONATORUM)

INTRODUCTION
Inflammation of conjunctiva during first 3 weeks of life is
termed as ophthalmic Neonatorum. Sticky eyes without
purulent discharge are common during first 2-3 days after birth.
Unilateral conjunctivitis after 5 days of life is often due to
Chlamydia trachomatis.
Purulent conjunctivitis with profuse discharge is usually
due to gonococcus which affects one or both eyes within 48
hours of age.
Other microorganisms causing neonatal conjunctivitis are
streptococcus, staphylococcus, pneumococcal, E.coli, herpes
simplex virus etc.
Chemical conjunctivitis may occur due to irritation of
silver nitrate, soap and local antibiotic drops.
DEFINITION
Ophthalmic neonatorum was the term used to describe a hyper
acute purulent conjunctivitis, usually caused by gonococcus, in
the first 10 days of life.
-WHO.
Ophthalmic neonatrum was the term used that any hyper acute
purulent conjunctivitis occurring during the first 10 days of
life, usually contracted during birth from infected vaginal
discharge of the mother.
-Medical Dictionary
Neonatal conjunctivitis is swelling (inflammation) or infection
of the tissue lining the eyelids in a newborn.
-Pub Med

MODE OF INFECTION
It includes infected hands of care givers, infected birth
canal and cross-infection from other infected infants.
Infection can occur directly from other sites of
infections like skin and umbilicus.

CLINICAL FEATURE
Varies with mode of infection and causative organism. The
neonate may present with sticky eyes with or without discharge
ranging from watery or purulent or muco purulent in one or
both eyes. The eyelids may be markedly swollen and stuck
together with redness of eyes. Closed eyelids may present due
to spasm of orbicularis oculi muscle.

PATHOPHYSIOLOGY
DIAGNOSTIC STUDIES
 Culture of the drainage from the eye to look for bacterial or
virus.
 Slit-lamp examination to look for damage to the surface of the
eyeball

MANAGEMENT
is done with specific antibiotic therapy, after identification of
causative organism.
 The baby should be isolated to prevent cross infection.
 Sulfacetamide or gentamycin or cholramphenicol drops
or erythromycin ointment can be used.
 For Gonococcal infection penicillin therapy should be
initiated promptly.
 If organism are resistant to Pencillin then cefotaxime or
ceftrioxone (50mg/kg IM or IV) are used.
 Cleaning of the infected eye with sterile cotton swabs
soaked in saline should be done after hand washing.
Instillation of eye drops be done with proper aseptic
techniques.

NURSING MANAGEMENT
 All infants should receive ocular prophylaxis at birth to
prevent Gonococcal Opthalmia. Neonates presenting with
signs of conjunctivitis should have a conjunctival swab
sent for Gram stain and culture. If Gram-negative
diplococci are present on the Gram stain results, the
 infants and their parents should be treated immediately
for presumed gonorrhoea.
 Infants with chlamydial infection should be treated with
oral antibiotics. Most of all other forms of bacterial
conjunctivitis can be treated with topical antibiotics, with
the exception of Pseudomonas infection.
 Infants should be followed during their treatment and
upon completion of therapy to ensure resolution of
symptoms. For cases in which sexually transmitted
bacteria are implicated, the mothers and their sexual
partners should be treated.
 Five clean practices should be followed during delivery;
clean hands, clean tie, clean blade and clean cord stump.
Sixth clean practice include clean clothing for mother &
baby
 Hand washing before and after handling the babies.
 Maintenance of cleanliness of the environment i:e
delivery room, neonatal care unit, postnatal area and
separate area for mother and baby at home

CONGENITAL SYPHILIS
 Syphilis is caused by Treponema pallidum.
 Congenital syphilis occurs when the spirochete
Treponema palladium is transmitted from a pregnant
woman to her fetus. Infection can result in stillbirth,
prematurity, or a wide spectrum of clinical
 manifestations; only severe cases are clinically WHO
apparent at birth.

RISK FACTOR
Baby has an increased risk of developing congenital syphilis in
following conditions:
 Lack of inadequate prenatal care of mother.
 Maternal substance abuse.
 Failure to repeat a serological test for syphilis in the third
trimester.
 Treatment failure.
 Inadequate access to Sexually Transmitted Diseases
(STD) clinics and STD outreach activities.

MODES OF TRANSMISSION
 Sexual contact.
 Trans-placental passage from infected mother.
 Contact with lesion at the time of delivery.
 The risk of developing syphilis after exposure is
about 40%.

TYPES
1. acquired syphilis
2. congenital syphilis
1.Acquired syphilis: is transmitted almost exclusively by
sexual contact, including oral sexual exposure. Less common
modes of transmission include transfusion of contaminated
blood or direct contact
with infected tissues
2. Congenital syphilis: results from transplacental
transmission of spirochetes. Women with primary and
secondary syphilis and spirochetemia are more likely to
transmit infection to the fetus than are women with latent
infection. Transmission can occur at any stage of pregnancy.
The incidence of congenital infection in offspring of untreated
or poorly treated infected women remains highest during the
first 4 yr after acquisition of primary infection, secondary
infection and early latent disease. Risk factors most commonly
associated with congenital syphilis are lack of prenatal care and
cocaine drug abuse, unprotected sexual contact, trading of sex
for drugs, and poor treatment of syphilis during pregnancy.

CLASSIFICATIONS
1. Early
2. Late
1. EARLY: It occurs in children between 0 and 2 years
old.
2. LATE: Late congenital syphilis is a subset of cases
of congenital syphilis
PATHOPHYSIOLOGY

CLINICAL MANIFESTATIONS AND LABORATORY

FINDINGS

Many persons infected with syphilis are asymptomatic for

years or do not recognize the early signs of disease.
 Hutchinson's trait
 Scarring skin around the mouth & nasal discharge
 Secondary lesions on feet
 Lesions on face
 Hutchinson's teeth (Abnormal notched and peg-shaped,
blunted upper incisor teeth)
 Saddle nose(collapse of the bony part of nose)
  Clutton's joints(swelling of joints)
 Sabre shins (malformation of tibia)
 Osteochondritis of distal radius and ulna
 Papulosquamous Plaques
 Osteochondritis of femur and tibia metaphysis

MANAGEMENT
Infected baby with positive serological reactions requires:
 Isolation from the mother
 Intramuscular administration of aqueous procaine
Pencillin G 50,000units per kg body weight each day for
10 days OR Aqueous crystalline Penicillin G 100,000-
150,000U/kg/day (given q8-q12hrs) IV for 10 days
 If >1 day of therapy missed, entire course should be
restarted
 Positive serological reaction without clinical evidences of
disease- the baby is treated with a single intramuscular
dose of penicillin G 50000 Units Per Kg Body Weight.
 An Apparently Healthy Child Of A Known Syphilitic
Mother- Serological Reaction Should Be Tested Weekly
For The First Month And Then Monthly For 6 Months.

Follow up
 Baby must have careful follow-up examination at 1, 2, 4,
6, and 12 months of age.
 Serologic non-treponemal tests: 3, 6, 12 months and end
of treatment (or until non-reactive)
  Non-treponemal Ab titers decline by 3 months of age,
and should be Non-reactive by 6 months, if infant was
not infected.(transplacentally acquires antibodies.)
 If persistent, stable titers, consider retreatment.
Congenital neurosyphilis- CSF exam at 6 month intervals
until normal

HIV AND AIDS

In 2009, the World Health Organization (WHO)
estimated that there are 33.4 million people worldwide living
with HIV/AIDS, with 2.7 million new HIV infections per year
and 2.0 million annual deaths due to AIDS. At the end of 2010,
there were 3.4 million children living with HIV around the
world. An estimated 3,90,000 children became newly infected
with HIV in 2010. HIV is primary cause of AIDS. There are
different strains of HIV. HIV-2 is prevalent in Africa, where as
HIV-1 is more common form in the United States. The
majority of children with HIV infection are younger than 7
years of age.

DEFINITION
 An infectious disease of the immune system caused by a
human immuno deficiency virus (HIV). AIDS is
characterized by a decrease in the number of helper T
cells, which causes a severe immune deficiency that
leaves the body susceptible to a variety of potentially
fatal infections. OR
  A disease of the immune system characterized by
increased susceptibility to opportunistic infections, as
pneumocystis carinii pneumonia and candidiasis, to
certain cancers, as as Kaposi's sarcoma, and to
neurological disorders caused by a retrovirus.

ROUTE OF TRANSMISSION

MATERNAL INFANT TRANSMISSION

 Intrauterine:25-40%
 Intrapartum:60-75%
 Added risk of brest-feeding:12-14%
RISK FACTOR OF PEDIATRIC AIDS
 Mothers who addicted with intravenous drugs.
 Mothers who indulge in prostitution.
 Mothers who are heterosexual with bisexual husbands.
 A history of blood transfusion with blood or its products
including factor-8 concentrates with in preceding 5 years.
 A history of residence in certain geographical areas that are
inhabited considerably with aids patients.

ETIOLOGY
 HIV is primary cause of AIDS. There are different strains of
HIV. HIV -2 is prevalent in Africa, where as HIV-1 is more
common form in the United States.
 Horizontal transmission of HIV occurs through intimate sexual
contact or pateral exposure to blood or body fluids containing
visible blood
 Vertical-perinatal transmission occurs when an HIV infected
pregnant women passes the infection to her infant.
 There is no evidence that the casual contact between the
infected and uninfected individual can spread the virus. The
majority of children with HIV infection are younger than 7
years of age.
 Children with HIV fall into two subpopulations: infants born to
HIV- infected women and adolescents infected as a result of
high-risk behaviours.
 The transmission of HIV can occur in utero, intrapartum, or
after delivery through breastfeeding.
 Nevirapine administered to the mother at labor and to the infant
within 48 to 72 hours of life is the most popular regimen in the
 developing world because of its ease of administration and low
cost
 The World Health Organization has recommended that
pregnant women be treated with an antiretroviral regimen
appropriate for their own health if possible Since breastfeeding
is essential for infant survival in developing countries,
 HIV mothers on antiretroviral treatment who exclusively
breastfed for a duration of their own choosing had lower HIV-1
breast milk concentrations than mothers who abruptly weaned
the infant at approximately 4 months of age
 Transfusion of infected blood or blood products has accounted
for 3% to 6% of all pediatric AIDS cases to date Sexual contact
is the leading source of exposure to HIV in the United States.
 In the young pediatric population this is an infrequent route of
transmission; a small number of children have been infected
through sexual abuse. In contrast, sexual activity is a major
cause of HIV infection in adolescents. Given that the average
time from HIV infection to the development of AIDS in adults
is 10 years.

CLINICAL MANIFESTATIONS
 Clinical manifestations found more commonly in children than
adults with HIV infection include
 Recurrent bacterial infections, chronic parotid swelling,
lymphocytic interstitial pneumonitis (LIP) and early onset of
progressive neurologic deterioration.
 Overall progression of disease is more rapid in children.
 Immune system is more immature than adults.
 Recurrent invasive bacterial infections are more common in
children.
  Disseminated CMV, Candida, Herpes Simplex and Varicella
Zoster are more common.
 CNS infections are common.
 Peripheral neuropathy, Myopathy is rare in children.

CATEGORIES
 The HIV classification system is used to categorize the stage of
pediatric disease by using 2 parameters: clinical status and
degree of immunologic impairment Among the clinical
categories,
 category A (mild symptoms) includes children with at least 2
mild symptoms such as lymphadenopathy, parotitis,
Hepatomegaly, Spleenomegaly, dermatitis, and recurrent or
persistent sinusitis or otitis media
 Category B (moderate symptoms) includes children with
LIP, oropharyngeal thrush persisting for >2 mo, recurrent or
chronic diarrhea, persistent fever for >I mo, hepatitis, recurrent
(HSV) stomatitis,
 HSV esophagitis, HSV pneumonitis, disseminated varicella
(i.e., with visceral involvement), cardiomegaly, or nephropathy
 Category C (severe symptoms) includes children with
opportunistic infections (e.g. oesophageal or lower respiratory
tract candidiasis, cryptosporidiosis (>1 mo), disseminated
mycobacterial or cytomegalovirus infection, Pneumocystis
pneumonia, or cerebral toxoplasmosis [onset >1 mo of age]),
recurrent bacterial infections. (sepsis, meningitis, pneumonia),
encephalopathy, malignancies, and severe weight loss.
WHO CLINICAL STAGING SYSTEM

Clinical stage-I
 Asymptomatic
 General Lymphadenopathy

Clinical stage-II
 Diarrhea>30 days
 Sever persistent or recurrent diarrhea outside neonatal period.
Weight loss
 Failure of thrive
 Persistent fever>30days
 Recurrent sever bacterial infection other than septicemia or
meningitis.(E.g. Osteomyelitis, abscess, Bacterial Pneumonia-
non tubercular)

Clinical stage-III
 Aids difining opportunistic infection
 Sever failure to thrive.
 Progressive encephalopathy.
 Malignanacy.
 Recurrent septicemia or meningitis.

DIAGNOSTIC EVALUATION
 For children 18 months of age and older, the HIV enzyme
linked immunosorbent assay (ELISA) and Western blot
immunoassay are performed to determine HIV infection.
  In infants born to HIV-infected mothers, other diagnostic tests
are used, most commonly the HIV polymerase chain reaction
for detection of proviral DNA. With this technique, almost all
infected infants can be diagnosed between 1 to 6 months of age

MANAGEMENT
 The goals of therapy for HIV infection include slowing the
growth of the virus, preventing and treating opportunistic
infections, and providing nutritional support and symptomatic
treatment.
 Antiretroviral drugs work at various stages of the HIV life cycle
to prevent reproduction of functional new virus particles.
Antiretroviral therapy regimens are continually evolving.
 Although antiretroviral drugs are not a cure, they can delay
progression of the disease. Classes of antiretroviral agents
include nucleoside reverse transcriptase inhibitors (e.g.,
zidovudine, didanosine, stavudine, lamivudine, abacavir);
nonnucleoside reverse transcriptase inhibitors (e.g., nevirapine,
delavirdine, efavirenz); and protease inhibitors (e.g., indinavir,
saquinavir, ritonavir, nelfinavir, amprenavir, lopinavir,
ritonavir).
 Combinations of antiretroviral drugs are used to stall the
emergence of drug resistance, which has been observed
historically in some children who received a single drug

IMMUNIZATION
 HIV-exposed children should be immunized according to the
routine national immunization schedule with the following
notes:
  BCG should not be given in symptomatic HIV- infected
children.
 HiB vaccine should be given to all who are confirmed HIV-
infected
 Additional vaccines such as Pneumcoccal, Varicella, Hepatitis
A, Influenza Virus etc. may be given as necessary.
 Vitamin A supplementation should be as per the UIP schedule.

NURSING CARE MANAGEMENT

 Education concerning the transmission and control of infectious
diseases, including HIV infection, is essential for children with
HIV infection and anyone involved in their care.
 The basic tenets of standard precautions should be presented in
an age appropriate manner, with careful consideration of the
educational level of the individual Safety issues, including
appropriate storage of special medications and equipment (e.g.,
needles and syringes) are emphasized.
 Unfortunately, relatives, friends, and others in the general
public may be fearful of contracting HIV infection, and
criticism and ostracism of the child and family may occur. In an
effort to protect the child and deal with the
community's fear, the family may limit the child's activities
outside the home.
 Although certain precautions are justified in limiting exposure
to sources of infections, they must be tempered with concern
for the child's normal developmental needs.
 Both the family and the community need ongoing education
about HIV to dispel many of the myths that have been
perpetuated by uninformed persons.
 Prevention is a key component of HIV education. Educating
adolescents about HIV is essential in preventing HIV infection
in this age-group.
 Education should include information on the routes of
transmission, the hazards of IV and other recreational drug use,
and the value of sexual abstinence and safe sex
practices
SUMMARY:

Till now we have discussed definition of newborn, newborn ww

profile, physical an physiological characteristics of newborn,
assessment of newborn, reflexes, nursing care of healthy newborn and
care to the Family.

CONCLUSION:

the goal of providing high quality care to all newborn infants can be
best achievement through continuing efforts by all participating
providers and institutions to develop and sustain communications.

Conclusion

BIBLIOGRAPHY
1) Dorothy R. Marlow and Barbara A. Redding. Text book
of pediatric Nursing. Elsevier publishers 6th edition 2005.
2) O.P.Ghai. Essential pediatric Jaypee brothers. Seventh
edition; 2005.
3) Wongs. Nursing care of infants and children. Elsevier
publishers. seventh edition;2006
4) Dr.B.T.Basavanthappa pediatric and child health nursing.
Ahuja publishing house. first edition,2005.