Until now, the assessment and treatment of problems that may present during birth or immediately after birth were addressed, specifically those relating to the newborn who is obtunded and distressed. This section will discuss those issues not directly related to the pregnancy or the act of delivery. This group of issues a newborn may face may not present for a few days to weeks after delivery.
Seizures in an infant often are related to a significant underlying issue, although they may be difficult to discern from other activities of the newborn. The causes of seizures in newborns are listed below. Seizures that occur within the first 3 days of birth are most likely caused by 1 of the first 3 causes on the list, whereas the rest of the list may begin after 3 days after birth.
Hypoxic events during or around birth can lead to hypoxic ischemic encephalopathy and is the single most common reason for seizures in the newborn, often with the fastest onset after birth, with the 1st seizure occurring as soon as 12 hours after birth. Seizures from this cause frequently start off subtly and worsen during the first few days of life. The newborn seizure should be differentiated from jitteriness. This is easily accomplished by gently applying pressure to a limb or passively moving 1 or more extremities. This will halt jitteriness, but it will not have any impact on a seizure. Jitteriness is not associated with eye deviations.
Hypoglycemia is noted separately from “other metabolic disturbances” because it is by far the most common metabolic disturbance to lead to seizures. The other metabolic disturbances include the following:
Assessment of the newborn would be incomplete without asking the mother about the situation surrounding birth, including normal versus cesarean, meconium staining, a nuchal cord, or any other prenatal complications. Hypoglycemia should always be assessed and treated as noted in the hypoglycemia section. Phenobarbital and benzodiazepines should be administered only under the advice of a physician.
Anyone who has ever been around a newborn knows all too well that he or she vomits. Often. Most of the vomiting that newborns do is seldom a cause for concern. It becomes worrisome if the vomiting interferes with weight gain, causes weight loss or dehydration, or appears bloody or bilious. Any of these may indicate a pathologic problem that needs to be addressed relatively quickly. As with vomiting at any age, aspiration is always a concern; it is especially concerning in newborns because they are not able to adjust to empty their mouths or avoid it when lying on their backs.
The causes of vomiting include the following:
Treatment for vomiting in the newborn will ultimately be related to the cause. Initially, manage the ABCs and attempt to establish intravenous access. Check the blood glucose level and treat if needed. Be prepared for further vomiting episodes and the need to suction or manage the airway. Dehydration may be indicated by sunken fontanels or skin tenting if the vomiting has been going on for more than 24 hours. A fluid bolus of 10 mL/kg is indicated in that case and can be repeated up to 3 times with the goal of a more active child. Antiemetics are not indicated in newborns.
Any infant born before the completion of the 37th week is considered premature or preterm. Often, there is no discernible reason for the child to have been born preterm; however, the following are some causes that may lead to prematurity:
Premature children face a difficult battle to simply survive outside the mother, especially the more remote the actual due date. They may fight through such issues as respiratory distress, respiratory suppression, and possibly apnea because of surfactant deficiency. Without surfactant, the lungs cannot slide smoothly, and the mechanics of breathing become immeasurably more labored. Preterm infants also are predisposed to infections and sepsis because of a poorly functioning immune system. Nervous system compromise is common with intraventricular hemorrhage and periventricular leukomalacia (a form of cerebral palsy). Nervous system disorders can be caused by extended periods of perinatal hypoxia or the administration of hypertonic solutions.
Preterm infants are not necessarily born with a low birth weight; however, it is the most common reason for a newborn to be of low birth weight. Low birth weight is any newborn of any gestational age weighing <2,500 g or 5.5 lb. An infant weighing <500 g is unlikely to survive overall, but the infant stands the best chance in a hospital with a neonatal intensive care unit.
The best treatment for any child born either preterm or low birth weight is to keep the child warm and provide respiratory support as needed during rapid transport to a hospital that is capable of taking care of high-risk infants. Respiratory support and oxygenation should be given only to ensure adequate breathing and heart rate and should not be provided simply as a matter of course. Although long-term O2 exposure can cause retinopathy of prematurity, which is abnormal development of the vasculature of the retinas, O2 should not be withheld from the infant who is hypoxic. This could essentially be sacrificing the brain to care for the eyes because the brain is much more sensitive to periods of diminished O2 supply.
Infants often are born with a yellowish tint to their skin called jaundice. In the adult, jaundice can be caused by hepatitis or liver failure; however, in the infant, jaundice is the result of the liver being unable to conjugate bilirubin during the first week of life. Infants have a higher mass of red blood cells, and it is believed that the increased rate of erythrocyte destruction and metabolism exceeds the liver’s ability to conjugate the resulting bilirubin. Generally, this is not a cause for concern, and it is almost a rite of passage for the newborn because it is seen to some degree in so many newborns. That said, bilirubin is neurotoxic, so high levels of bilirubin need to be addressed. The paramedic will not be able to address or meaningfully treat neonatal jaundice except to know that it will likely be the reason for altered mental status in a newborn with yellowish skin. The paramedic can start an intravenous line on the infant to temporarily dilute the bilirubin and to help minimize long-term effects; however, transport to the hospital is ideal.
The newborn’s thermoregulation system is immature and does not respond as in older children or adults. Newborns do not sweat to release heat; they are not able to shiver to generate heat when they are cold. As a result, newborns can become overheated when bundled in a heated car or in direct sunlight or may even become cold when they are in an otherwise comfortably heated house. Newborns have a higher volume-to-surface-area ratio, which means that even under normal circumstances they will lose body heat faster, even in warmer temperatures.
Fevers in newborns are relatively rare and often are not the presenting feature of an infection. Newborns can actually become hypothermic during an infection and are at higher risk for hypoglycemia and metabolic acidosis because of the immune response. Neonates with illnesses often become somnolent, have a reduced appetite, and wet fewer diapers.
Hypothermic newborns are a cause for concern because this is more likely the presenting sign of illness. Hypothermia also leads to increased metabolic activity to try and generate heat because they cannot shiver, leading to hypoglycemia and possibly metabolic acidosis. As hypothermia progresses, they may slow their respirations or become irritable. They also may have acrocyanosis (cyanosis of the hands and feet) or become bradycardic. To rewarm the neonate, skin-to-skin contact is the best and can be used after drying the infant and placing the infant on the mother. Avoid using heated water bottles or heating pads, which can cause burns or hyperthermia.
A variety of congenital heart diseases (CHDs) are listed here, and the paramedic should have at least a working knowledge of them. Aside from the supportive measures mentioned throughout this chapter, EMS will not be able to do much for the infant with these conditions. Fortunately, many are not immediately life threatening upon birth; however, most will require surgery, often within 6 months or so after birth. The conditions and the most common signs or symptoms are presented.
