Complications During the Neonatal Period: The High-Risk Newborn

4. Disorders affecting nutrition: infant of the diabetic mother (IDM)
   1. Pathophysiology - hyperplasia of pancreatic beta cells —> increased insulin production —» excessive deposition of glycogen in muscles, subcutaneous fat, and tissue growth. Results in fetal:
      1. Macrosomia - LGA infant.
      2. Enlarged internal organs - common.
         1. Cardiomegaly.
         2. Hepatomegaly.
         3. Splenomegaly.
      3. Neonatal - inadequate carbohydrate reserve to meet energy needs.
      4. Associated with increased incidence of:
         1. Congenital anomalies (five times average incidence with pregestational diabetes) includes cardiac, pelvic, and spinal anomalies.
         2. Preterm birth: respiratory distress syndrome (RDS); increased insulin needs prenatally lead to decreased surfactant production.
         3. Fetal dystocia - due to CPD.
         4. Neonatal metabolic problems:
            1. Hypoglycemia.
            2. Hypocalcemic tetany.
            3. Metabolic acidosis.
            4. Hyperbilirubinemia.
   2. Etiology - high circulating maternal glucose levels during fetal growth and development; loss of maternal glucose supply following birth; decreased hepatic gluconeogenesis.
   3. Assessment:
      1. Characteristics of IDM.
      2. Hypoglycemia - Dextrostix or Chem-strip to heel stick at:
         1. 30 minutes X 2.
         2. 1, 2, and 4 hours of age; before meals X 4 or until stable.
         3. Chemstrip: if < 20 mg/dl , must draw glucose stat.
         4. Hypoglycemia laboratory values for term infant: under 40 mg/dl.
         5. Hypoglycemia laboratory values for preterm infant: under 40 mg/dl.
         6. Behavioral signs - tremors; twitching, hypotonia, seizures.
      3. Gestational age, since macrosomia may mask prematurity.
      4. Hypocalcemia - usually within first 24 hours
         1. Irritability.
         2. Coarse tremors, twitching, convulsions.
      5. Birth injuries.
         1. Fractures: clavicle, humerus, skull.
         2. Brachial palsy.
         3. Intracranial hemorrhage/signs of increased intracranial pressure.
         4. Cephalohematoma.
      6. Respiratory distress.
         1. Nasal flaring.
         2. Sternal retraction.
         3. Intercostal retractions.
         4. Cyanosis - central.
         5. Expiratory grunt.
      7. Jaundice.
   4. Analysis/nursing diagnosis:
      1. High risk for injury related to CPD, dystocia.
      2. Altered cardiopulmonary tissue perfusion related to placental insufficiency, RDS.
      3. Impaired gas exchange related to RDS.
      4. Altered nutrition, less than body requirements, related to hypoglycemia, hypocalcemia.
      5. Risk for altered endocrine/metabolic processes related to hyperbilirubinemia and kernicterus.
   5. Nursing care plan/implementation:
      1. Hypoglycemia - administer formula or IV glucose, as ordered (may cause rebound effect).
      2. Preterm/immature - institute preterm care prn.
      3. Hypocalcemia - administer oral or IV calcium gluconate, as ordered.
      4. Inform pediatrician immediately of signs of:
         1. Jaundice.
         2. Hyperirritability.
         3. Birth injury.
         4. Increased intracranial pressure/hemorrhage
   6. Evaluation/outcome criteria:
      1. Infant makes successful transition to extrauterine life.
      2. Infant responds to medical/nursing regimen. Experiences minimal or no metabolic disturbances (hypoglycemia, hypocalcemia, hyperbilirubinemia).
      3. Infant exhibits normal respiratory function and gas exchange.