1
Q
What are 4 adaptations are required for infants to transition to extrauterine life?
A
- circulatory pathway
- Respiratory: lungs must inflate for gas exchange
- thermal stability: outside the warm intrauterine
- glucose homeostasis: without access to maternal glucose supply
- foreign and pathogenic microorganisms
- environment: noise, light, touch
- stooling and voiding patterns
2
Q
What are some risks commonly associated with early maternity discharge (3)?
A
- breastfeeding issues/ feeding issues
- jaundice
- dehydration
- postpartum depression
3
Q
What is critical congenital heart disease (CCHD)?
A
- most common congenital malformation
- leading cause of infant death in Canada
- defined as more severe and often duct-dependent lesions that require intervention early in life for optimal outcome
4
Q
What are the primary targets for CCHD screening (3)?
A
- hypoplastic left heart syndrome,
- pulmonary atresia with intact ventricular septum,
- transposition of the great arteries,
- truncus arteriosus,
- tricuspid atresia,
- tetralogy of Fallot, and
- total anomalous pulmonary venous return
5
Q
Why is it important to perform CCHD pulse oximetry screening?
A
- CHD is the leading cause of infant death in Canada (prevalence of 12/1000 live births in Canada)
- Early diagnosis is crucial for decreasing morbidity, mortality and disability related to delayed diagnosis of CHD
6
Q
How is CCHD pulse oximetry screening performed?
A
- testing should be done between 24 and 36 hours of age
- test includes pulse oximetry measurement of preductal (right hand) and postductal (either foot) oxygen saturations
- baby passes the screening if the oxygen saturation is 95% or greater in the right hand and foot and the difference is three percentage points or less between the right hand and foot
- screen is immediately failed if the oxygen saturation is less than 90% in the right hand and foot
7
Q
Why is CCHD pulse oximetry not done prior to 24hours of age?
A
- testing prior to 24 hours significantly increases the rate of false positives due to transition from fetal circulation
8
Q
When would the CCHD pulse oximetry screen must be repeated?
A
- oxygen saturation is greater than 90% and less than 95% in the right hand and foot,
- or there is more than a three-percent difference between the right hand and foot,
- then the screen must be repeated in one hour according to the same process as above
9
Q
What happens if infant fails the CCHD pulse oximetry screening?
A
Infant should be examined by the most responsible health care provider:
- make sure the baby is hemodynamically stable, and
- the infant should also be evaluated for hypoxemia.
- could involve evaluating for sepsis or pneumonia.
- Any signs or symptoms of congenital heart disease should prompt rapid evaluation, including potential transfer to a centre with advanced care capabilities
10
Q
After a failed CCHD pulse oximetry and cardiac diagnosis cant be excluded, what happens next (2)?
A
- cardiologist or neonatologist should be consulted
- an echocardiogram should be performed
11
Q
What setting is CCHD pulse oximetry recommended to be used in?
A
- intended for use in asymptomatic newborns in non-acute care settings
- not for preterm newborns or in NICU setting
12
Q
Spencer was born at 38+2 weeks GA and is now 24 hours old. His Sp02 was 90% on his right hand and 94% on his right foot. Spencer’s nurse repeats the screening in one hour and his Sp02 is now 89% on his right hand and 88% on his right foot. The next step is to:
A
- Call the most responsible health care provider as Spencer has failed his screening.
13
Q
Benjamin was born at 37+2 weeks GA and is 36 hours old. His Sp02 was 94% on his right hand and 93% on his left foot. The next step is:
A
- Repeat the screening in one hour.
14
Q
Sophia was born at 38+6 weeks GA and is 30 hours old. Her Sp02 is 95% on her right hand and 96% on her right foot. Sophia has passed her CCHD screening.
A
- True
15
Q
What are some concerns of Claires history?
A
- Maternal age > 35 years: Many women are having their children later in life.
- Previous pregnancy loss: increased risk for postpartum depression or at least postpartum adjustment
- Single parent: as above
-Epidural for caesarean section: associated with increased jaundice and decreased breastfeeding - Pain: impedes effective breastfeeding
- Blood loss: > 500 cc—associated with decreased prolactin levels
16
Q
During home visits, what should be asked?
A
- begin with an open-ended questions to allow mother to set the agenda and identify what her priorities are
- give parents a chance to identify their own needs.
- Consider starting with how a mother is feeling.
- directly ask mothers about themselves, you may miss important information: for example, pain or how they are coping.
17
Q
What are 4 factors that influence a mother whether to breastfeed or formula feed?
A
- antenatal influences
- previous breastfeeding experience
- support
- challenging situations: breast surgery
- return to work outside the home
18
Q
What are 4 feeding education to inform childbearing women and their families?
A
- benefits of breastfeeding
- anatomy of breast
- physiology of breastfeeding,
- sources of support and information, and
- alternative methods of feeding expressed breast milk
19
Q
Formula-fed infants are at increased risk of health problems compared to breastfed infants.
A
- True
20
Q
The main carbohydrate in breastmilk is:
A
- Lactose
21
Q
Carbohydrates known as oligosaccharides in breastmilk promote:
A
- Growth of probiotics in the infant’s gut
22
Q
Babies will feed most effectively when they are in which of the following states?
A
- quiet alert
23
Q
Which hormone is responsible for the milk-ejection reflex?
A
- oxytocin
24
Q
The rate of milk synthesis is influenced by:
A
- regular and thorough emptying of the breast
25
When is the best time to establish the first feed?
- in the first hour of life
26
Which of the following has been shown to improve both breastfeeding initiation and duration rates?
- Unrestricted skin-to-skin contact
27
A correct latch may appear asymmetrical, with more areola visible at the top of the breast.
- true
28
When there is an effective latch, the infant should suck continuously with no breaks.
- False
29
Cluster feeding is a sign that there is insufficient milk supply.
- false
30
Suggest a breastfeeding position for a mother who had a C-section six hours ago.
- football position
- not side-lying
31
What is the correct description of the fat composition of human milk?
- Fat is the main source of energy for the infant and the most variable component in breast milk.
32
What are 3 signs breastfed baby is eating enough?
- after nursing: breasts feel softer
- baby should seem relaxed and satisfied after feed
- first few days: 1 to 2 wet diapers a day and 1 to 2 dirty diapers a day
- when milk comes in: 6+ wet diapers a day and 3 dirty diapers a day
33
What are 4 signs baby is not getting enough milk?
- excessive weight loss
- dark urine
- small dark stools
- fussy or lethargic
- dry and cracked lips
34
What are early hunger feeding cues (3)?
- smacking lips
- turning head side to side
- mouthing and sucking motions.
- rooting: turn towards her breast and open his mouth
35
What are 3 ways to help mother thats about to feed her infant?
- help mom get into a comfortable position (either sitting or lying down),
- using pillows to support her back, head, and both her arms.
- help her to position her baby to facilitate feeding.
- baby should be tummy-to-tummy, and preferably skin-to-skin, with Claire being propped on pillows or supported so that his body is level with Claire’s breast have his head and body in a straight line (the baby should not have to turn his head to reach the breast)
36
What are 5 steps to help mom feed baby for a proper latch?
- Support her breast, with her thumb on top and four fingers underneath (the C-hold),
- positioned well back from the areola (“present” her breast to the baby),
- wait until her baby’s mouth is wide open, then lead with the chin, draw her baby firmly towards her breast (centre the nipple in the space between the tongue and the baby’s upper lip),
- see that her baby’s lower jaw is as far back as possible from the nipple (as much tongue on as much breast as possible)
- tuck her baby’s body in close to her own body.
37
What are signs of a good latch (3)?
- woman feels tugging sensation on her nipple
- cheeks are rounded, not sucked in or dimpled
- baby mouth wide open
- baby’s lower lips is flanged outwards
- babys tongue is cupped beneath the mothers breast
- tips of baby nose, chin are touching the breast
38
What are 3 signs of a good suck?
- baby begins breastfeeding with a period of quick sucking to stimulate the mother’s let down or milk-ejection reflex.
- After the initial let-down occurs, the sucking becomes deep and rhythmic
- hear regular audible swallowing
- she shouldn’t hear audible smacking or clicking sounds.
- observable “wiggle” at the junction of the baby’s ear and temple.
- Breastfeeding will be comfortable for her
- A baby who is sucking well will stop feeding when finished
39
How often and how long should mom feed her infant?
- feed as often/many times as he likes, and for as long as he likes
- normal for a newborn to feed every 2-3hours during the day and 3-4 hours at night,
- should feed at least 8 times in 24 hours.
- feed for different lengths of time, often for about 20-30minutes but sometimes for shorter or longer periods.
- 15−20 minutes at each breast
- some infants will nurse on only one breast at each feed
breastfed babies should be feed as often as they like for as long as they like. but at least 6 times in 24 hours?
40
Why is position and latch important for successful breastfeeding?
- Problems with position and latch can lead to sore nipples
- This makes it difficult for mothers to continue breastfeeding.
- Poor position and latch also interfere with the delivery of milk to the infant.
- This can affect the demand/supply relationship.
41
What are some components of breast milk composition?
- water
- protein
- carbohydrate/lactose
- various fats
- antibodies
- vitamins/minerals
- human milk oligosaccharide
- 800 strains of bacteria
- other immune cells
- hormones
42
What is the nature of human milk as it relates to the frequency and duration of feeds in 24-hour period?
- the longer the baby feeds and effectively removes milk from the breast, the higher the fat content rises in the milk during the feed.
- the longer the interval between feeds, the lower the fat concentration will be at the start of the next feed.
- Because of this changing composition (especially in the concentration of fat content) of breast milk during each feeding, it is important to breastfeed the infant long enough and often enough (8−12 feeds in 24 hours) to supply a balanced feeding.
43
What are 3 reasons why ill term infants and preterm infants are at greater risk for fluid and electrolyte imbalance?
- higher body water content
- thinner skin leading to higher insensible water loss from a larger surface area
- more immature kidneys
- reliance of IV fluids
44
What are 3 reasons to why infants are prone to dehydration?
- have more body water: more of that water is extracellular,
- their total body water turnover is higher,
- their evaporative water losses are higher, and
- their kidneys are less able to conserve water by concentrating urine.
45
What is key indicator of hydration status? What are 3 other assessment of hydration?
- weight (key indicator of hydration status)
- tissue turgor,
- mucus membranes,
- fontanel,
- urine output, and
- serum sodium
46
In hospital setting, what is a good indicator of hydration aside from weight?
- serum sodium is a good indicator of hydration.
- Increased serum sodium often indicates loss of fluid from the body, leaving excess salt in the serum.
47
What is critical indicator of adequate intake?
- infant weight
48
What is considered a normal range of weight loss in first few days of life?
- weight loss of 5%–10% of the birth weight is considered acceptable
- This initial weight loss should be regained within 7–10 days as muscle and fat if breastfeeding is going well (approximately 28–30 grams per day).
49
What is the formula to calculate percentage weight loss?
birthweight - current weight/ birth weight x 100
- normal to lose up to 5-10%
- should regain by day 10 (2weeks)
50
What is jaundice?
- baby’s skin and whites of the eyes turn a yellow colour
- Yellowish discoloration of the skin. Can be due to both physiologic and pathologic processes
51
How do babies become jaundice?
- when they have too much bilirubin in their blood
- means either the body is making too much bilirubin or the liver is not getting rid of it quickly enough
52
What is bilirubin?
- normal pigment made when RBC breaks down in body
- usually processed by the liver, recycled and eliminated in the babys stool
53
What reduces the risk of jaundice?
- feeding (esp breastfeeding) in the first hours and days after birth
- by promoting the passing of stool and excretion of bilirubin
54
What is hyperbilirubinemia?
- Elevated blood bilirubin levels
55
What is the difference between physiologic jaundice and pathologic jaundice?
- pathologic jaundice: Due to abnormal processes such as blood group incompatibility, excessive bruising, or sepsis
- physiologic jaundice: Due to normal processes
56
What are 5 steps bilirubin metabolism and excretion in the newborn?
- When red cells, at the end of their 120-day life-span, go to the spleen, they are systematically dismantled.
- Through a series of biochemical steps, the heme is changed into bilirubin.
- The bilirubin is greedily taken up by the liver, conjugated with glucuronide, and deposited into the alimentary tract in the bile,
- then converted to urobilinogen by colonic bacteria.
- The urobilinogen is excreted in the stool (most of it) or reabsorbed and excreted in the urine (very little of it).
57
What does seeing pink tinge staining in diapers mean?
- pink staining on the diaper may be a benign finding sometimes seen in newborns, or
- it may be evidence of uric acid crystals, which are evidence of highly concentrated urine
58
What are major signs of dehydration in infants (3)?
- increased serum sodium
- decreased tissue turgor
- sunken fontanel
- dry mucous membranes
- decrease urine output
- weight loss
59
What is the relationship between vulnerability due to prematurity and dehydration (3)?
- kidneys cannot concentrate urine
- total body water content is high
- extracellular water content is high
- water turnover is high
- evaporative losses (skin and respiratory track) are high
60
What is Kernicterus (or bilirubin encephalopathy)? What are 3 long term effects?
- refers to the damage that bilirubin can inflict on an infant’s brain.
- Kernicterus is a potential complication of hyperbilirubinemia.
- The long-term effects include developmental delays, vision problems, deafness, seizures, and cognitive deficits.
61
How is kernicterus related to infant vulnerability?
- Preterm infants are at greater risk for kernicterus because their blood–brain barrier is poorly functional.
- In addition, infants who are hypoxic, infected, and/or dehydrated are at greater risk for kernicterus.
62
What are risk factors associated with postpartum mood disorders (3)?
- pre-existing depression,
- preterm birth,
- multiples,
- age (especially adolescence),
- low income and
- poor social support
63
What are the 3 categories that postpartum mood disorders are divided into?
- postpartum blues
- postpartum depression
- postpartum psychosis
64
What is postpartum blues ("baby blues")? Symptoms?
- Postpartum blues are relatively benign and short term;
- symptoms: feeling sad, tearfulness, irritability, mood swings, anxiety, worry, and physical and mental exhaustion
- These symptoms usually start within a couple days of birth
- can generally last about two weeks
65
What is postpartum depression?
- Is experienced by 10-20% of women during the first year after birth
- Postpartum depression, while more severe, is still fairly common.
- Symptoms usually appear within the first month postpartum
- include lack of interest in usual activities, depressive mood, hopelessness, appetite disturbances, inability to sleep, irritability or anger, and even thoughts of self-harm and harm of the infant.
- Postpartum depression may initially be mistaken for postpartum blues, but the symptoms are more intense, last longer, and may interfere with the mother’s ability to care for her baby
66
What is postpartum psychosis?
- Postpartum psychosis is characterized by intense symptoms, such as delusions, hallucinations, extreme irritability, paranoia, sleep disturbances and hyperactivity,
- which usually occur within the first two weeks after birth.
- It is an emergency and requires immediate help due to the risk for self-harm and harm of the infant.
67
What plays a big role in sibling adjustment?
- Age
- some children experience emotional and behavioural problems such as aggression, sleep problem, anxiety and withdrawal
68
What are 4 options for support of new parents and families available in your community?
- family
- friends/neighbours
- community centre programs
- community health department programs
- new moms or parenting support groups or drop-ins
- church groups
- postpartum support groups
- reproductive psychiatry programs
- breastfeeding drop-in clinics
- La Leche League
- independent lactation consultants
- independent home nursing care programs
- loss and grief support groups
- Internet support groups
69
What are 4 benefits of breastfeeding for preterm infants?
- protection from NEC
- protection from infection and sepsis
- increased feeding tolerance
- decreased risk for allergy
- improved retinal function
- improved neurocognitive development and brain growth
- suppression of oxidative stress
- reduced heart disease in later life
70
What are 4 factors as per AAP for the "Call to action to support breastfeeding"?
- all infants should be breastfed
- human milk is uniquely superior for infant feeding
- infants should be exclusively breastfed for 5-6months
- breastfeeding is the ideal method of feeding and nurturing infants
71
What are the 10 steps to successful breastfeeding?
- establish ongoing monitoring
- ensure staff have sufficient knowledge, competence and skills to support breastfeeding
- discuss importance of breastfeeding to woman and families
- facilitate uninterrupted skin to skin contact
- support mothers to initiate, maintain breastfeeding
- do not provide breastfed infant any food or fluid other than breastmilk
- enable mother and infant to remain together (rooming in)
- support mother to recognize/respond to infants cues for feeding
- counsel mother on use and risk of feeding bottle, pacifiers
- coordinate discharge so parents have timely access to ongoing support and care
72
What 4 factors affect components of breastfeeding?
- stage of lactation
- time of day
- sampling time during a feeding
- extremes of maternal nutrition
73
When is colostrum produced? When does it change to transitional milk and mature milk?
- colostrum: milk is yellowish, thick
- at delivery: colostrum produced
- within 5 days: changes to transitional milk
- by 2 weeks: finally mature milk
74
Why should pumped milk be labelled chronologically?
- so that it is fed to preterm infants in the same sequence in which it was collected
- this way, preterm infant receives the high concentration of protective qualities
75
What are ways colostrum feeding done in NICU (3)?
- colostrum first feeding received by newborn infant
- colostrum may be used for minimal enteral nutrition (trophic feeds)
- colostrum safely administered to the oropharynx
- give exclusive colostrum feedings for the first 3-4 days then alternate colostrum with fresh mature human milk
76
What does providing colostrum to the oral cavity of preterm stimulate (2)?
- development
- response to neonates own immune system
77
What are 4 hormones that stimulate breast development during pregnancy?
- luteal and placental hormones
- lactogen
- prolactin
- chorionic gonadotropin
78
What is mammmogenesis?
- growth and development of the grandular tissue of the breast and differentiation of secretory epithelial cells
79
What does estrogen and progesterone stimulate?
- estrogen: stimulate growth of milk collection (ductal) system
- progesterone: stimulate growth of milk production system
NOTE: these hormones inhibit initiation of breast milk production (they inhibit breast receptors for prolactin)
80
How does stimulating nipple by infant sucking produce milk?
- infant sucking action causes increase in prolactin in bloodstream and induce synthesis and release of oxytocin
- prolactin stimulate synthesis and secretion of milk
- adequate prolactin secretion controls the maintenance of milk supply
= the sooner the infant nurses, the sooner milk comes in and becomes established
81
What are 4 rewards to the mother from breastfeeding?
- enhancing coping mechanisms with caring for a new family member
- diminish maternal stress related to physical/interpersonal stress
- knowing that she is providing the healthiest nutrition
- enhancing closeness to her infant
- perceiving infant contentment during breastfeeding
- convenience for mother
82
What are 3 benefits of kangaroo care at birth?
- facilitate early initiation of breastfeeding
- increases maternal confidence and competence
- increases breastfeeding duration
83
What is the difference between nonnutritive sucking and nutritive sucking?
- nonnutritive sucking: sucking activity in which no fluid or nutrition is delivered to infant (short burst of rapid motion, pauses, few swallows.
- nutritive sucking: used by infant when fluid or nutrition is available (organized rhythmic pattern)
- during nutritive sucking: each milk expression is followed by a reflexive swallow and brief pause
84
What factors about infant affect nutritive sucking? (3)?
- maternal anesthesia
- length of labour
- type of delivery
- gestational age
- birth weight
- age (in hours)
- severity of illness
- infant state
- disorders of CNS
85
What are the two patterns of nutritive sucking?
- continuous sucking: occurs at the beginning of bottle feeding when the suck is strong and continuous for 30 seconds
- intermittent sucking: an alternation of sucking bursts with periods of pause/no sucking
86
What is the sucking-to-breathing ratio for preterm vs full term newborn?
- preterm sucking-to-breathing ratio is 2:1 to 4:1
- full term sucking-to-breathing ratio is 1:1
87
What kind of coordination does nutritive sucking requires?
- coordination between sucking, swallowing and breathing
- during coordinated sucking bursts: suck-swallow-breathing occurs in 1 sec: 1 sec: 1 sec sequential pattern
88
What are the 5 interrelated processes that human nutritive sucking is composed of?
- rooting: tactile stimulation of infants face and lips, elicit head to turn toward stimulus
- orienting/latching on: tongue draws the nipple and areola into an elongated teat and compresses it against the hard palate
- sucking: application of negative pressure in infant mouth with lowering of tongue, elongate nipple and transfer milk from breast
- expressing: occurs when negative pressure is applied to the breast with closure of mandible that compresses milk ducts
- swallowing: occurs as peristaltic motion of posterior pharynx and propulsion of milk down esophagus
89
Why is breastfeeding consider as infant-regulated system?
- milk flow depends on active sucking by infant
- when infant pauses to regain physiological stability, the flow of milk from breast ceases
90
How are artificial nipples and bottles considered gravity-regulated systems?
- artificial nipples vary rate of milk flow: fluid flows into the posterior oropharynx by gravity
- gravity-regulated systems: requiring infant to actively inhibit milk flow to permit swallowing and breathing
- to regulate milk flow and prevent choking/gagging, infant may clench their jaw or obstruct the nipples holes with their tongues in a thrusting motion
