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Overview of General Problems in Newborns

By Robert L. Stavis, PhD, MD, Clinical Director, Neonatal ICUs; Associate Professor, Department of Pediatrics, Main Line Health, Bryn Mawr, PA; Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children; Thomas Jefferson University Hospital

Problems in newborns may develop

  • Before birth while the fetus is growing

  • During labor and delivery

  • After birth

About 10% of newborns need special care after birth due to prematurity, problems with the transition from fetal to newborn life, low blood sugar, difficulty breathing, infections, or other abnormalities. Specialized care is often given in a neonatal intensive care unit (NICU).

Gestational age

Gestational age refers to how far along the fetus is. Many issues that affect newborns are related to the gestational age because it reflects the newborn's degree of physical maturity at birth. The gestational age is the number of weeks that have passed since the first day of the mother's last menstrual period. This time frame is often adjusted according to other information doctors receive, including the results of early ultrasound scans, which give additional information regarding the gestational age. Babies are estimated to be due (the due date) at a gestational age of 40 weeks.

Newborns are classified by gestational age as

  • Premature: Delivered before 34 weeks of gestation

  • Late preterm: Delivered at 34 to before 37 weeks of gestation

  • Term: Delivered at 37 to before 41 weeks of gestation

  • Late term: Delivered at 41 to before 42 weeks of gestation

  • Postmature: Delivered at 42 weeks or more of gestation

The physical features of the newborn are also characteristic of the gestational age (see Physical Features of a Premature Newborn).

Problems Before Birth

Problems in a newborn may have begun before birth.

Problems that develop before birth may be related to conditions in the mother that existed before the pregnancy or developed during the pregnancy, or to conditions in the fetus. Appropriate medical care during pregnancy can help prevent and diagnose many problems in the fetus.

Maternal health problems

The mother's health problems during pregnancy can affect the growing fetus and negatively impact the health of the newborn. Although mothers rightly worry about the effects of medications on a developing fetus, they also must realize that failing to take necessary treatments can allow their medical disorders to harm the fetus. Women should discuss with their doctor the risks and benefits of different treatments for their specific conditions.

Anorexia and bulimia can cause the fetus to receive inadequate nutrition, as does any other situation in which the mother does not eat adequately or take appropriate vitamins.

Asthma does not usually affect the fetus as long as the mother's condition is well controlled. However, some women have significant problems with their asthma during pregnancy and must take appropriate treatment to protect the fetus.

Cancer itself does not usually affect the fetus, but drugs used to treat cancer may have side effects.

Diabetes may result in an increased risk of birth defects, a small baby, or a large baby. The most common problem for newborns is low blood sugar (hypoglycemia).

Epilepsy (a seizure disorder) increases the risk of birth defects. Some of the increased risk is due to the anticonvulsant drugs that may be necessary to control seizures. However, the mother's seizures also are dangerous for the fetus. Women should discuss with their doctor the risks and benefits of drug treatment before they stop taking their anticonvulsants.

High blood pressure, heart disease, and kidney disease may reduce the growth of the fetus and cause other complications.

Lupus (systemic lupus erythematosus) increases the risk of miscarriage and prematurity and can cause an abnormally slow heart rate in the fetus.

Preeclampsia can cause severe problems for the mother and fetus. The disease can cause the mother's blood pressure to become severely elevated and can affect the mother's kidneys, liver, brain, and other organs. The placenta too is affected, and the disease can affect the nutrition of the fetus or cause the placenta to detach from the wall of the uterus. To prevent or manage such complications, doctors may recommend early delivery.

Women who have sickle cell disease may have increased sickle cell crises during pregnancy. If the father carries the sickle cell gene or is affected by sickle cell disease, there is a risk of sickle cell disease in the offspring. Testing of the parents before pregnancy can determine their risk of having a child with sickle cell disease. Genes that cause sickle cell disease can be detected in the fetus during the pregnancy, but the disease does not start until several months after birth.

Thyroid disease that causes a low thyroid hormone level (hypothyroidism) may cause brain damage in the fetus and lead to long-term neurologic problems. Thyroid disease with a high thyroid hormone level (hyperthyroidism) may cause the fetus and newborn to have an overactive thyroid gland.

Maternal drug use

Most prescription drugs are safe during pregnancy, but women should review all their drugs with their doctor when they become pregnant or plan to become pregnant. However, even prescription drugs that cause some risk may still be necessary for women. Uncontrolled medical problems in the mother also can be dangerous to the fetus. Some common prescription drugs that can cause problems for the fetus include

Smoking or being exposed to second hand smoke during pregnancy decreases the growth of the fetus. Pregnant women should avoid exposure to tobacco smoke as much as possible.

Alcohol is particularly dangerous to the fetus because it is a teratogen (a substance that can cause birth defects). Alcohol increases the risk of miscarriage, stillbirth, poor growth of the fetus, prematurity, and birth defects. A particularly devastating effect of alcohol is fetal alcohol syndrome, which causes life-long intellectual, developmental, and behavioral disabilities. There is no safe amount of alcohol during pregnancy.

Opioid drugs, such as heroin, morphine, opium, oxycodone (OxyContin®), codeine, hydrocodone, fentanyl, hydromorphone (Dilaudid®), meperidine (Demerol®), buprenorphine, and methadone, affect the growth of the fetus and can cause withdrawal symptoms in the newborn beginning hours to several days after birth. These and other opioids, particularly those combined with other drugs such as acetaminophen, are prescribed under many different brand names (some of which in the United States include Lorcet®, Lortab®, Norco®, Vicodin®, Percocet®, Endocet®, Roxicet®, and Tylenol®#3). Mothers should be aware of the ingredients of any painkiller they take. Opioid drugs such as methadone and buprenorphine that are sometimes used to treat a mother's opioid dependence also can cause withdrawal symptoms in newborns. Newborns withdrawing from methadone may need longer treatment than newborns withdrawing from other opioids.

Cocaine increases the risk of poor growth of the fetus and prematurity. The premature separation of the placenta from the wall of the uterus (placental abruption) is more common among cocaine users and can cause stillbirth or oxygen deprivation and brain damage in the fetus. Because cocaine narrows blood vessels, it can cause a stroke or damage other organs in the fetus. Although cocaine was once widely thought to cause permanent brain injury, long-term studies have not shown the intellectual and developmental disabilities as seen with maternal alcohol use.

Maternal lifestyle

In addition to avoiding harmful substances, expectant mothers can improve the chances of having a healthy baby by taking prenatal vitamins, receiving early prenatal care, and maintaining a healthy weight and diet (see also Self-Care During Pregnancy).

Fetal problems

Birth defects can involve almost any organ. Widespread use of prenatal ultrasonography diagnoses many of these defects before birth.

Problems After Birth

Some newborns, especially those prematurity, have problems that develop or are discovered after birth. Disorders may affect various organ systems in the body.

Some disorders that affect the lungs and breathing include

Some disorders that affect the blood include

Some disorders that affect the hormones include

Some disorders that affect the gastrointestinal tract and liver include

There are diseases that affect other systems in the newborn's body as well, such as retinopathy of prematurity, which affects the eyes of some premature newborns.

Diagnosis

  • Before birth, ultrasonography

  • After birth, various tests

Some problems in newborns may be diagnosed before birth if the mother is receiving regular prenatal care. Other problems are diagnosed after birth.

Diagnosing problems before birth is particularly helpful for fetuses with certain birth defects. Mothers and their doctor can then plan to deliver such infants in a hospital capable of providing a higher level of newborn care, including having a neonatal intensive care unit (NICU).

Diagnostic tests before birth (prenatal care)

Ultrasonography is used before birth to detect many problems and monitor the growth and development of the fetus. Ultrasonography helps doctors determine the sex of the fetus, detect abnormalities in the uterus, detect certain birth defects, and determine the fetus's gestational age. Knowing the fetus's gestational age and birth defects helps doctors anticipate problems that could develop at birth. However, ultrasonography is not 100% accurate. Some babies are born with birth defects that were not detected with ultrasonography.

Fetal echocardiography, a detailed examination of the heart using a specialized ultrasound device, may be done to detect certain heart defects.

A sequential screen is a 2-step test to detect Down syndrome (trisomy 21), trisomy 18, spina bifida, and several other abnormalities in the fetus. The first step is done during the first trimester and involves testing the mother's blood for certain hormones and proteins, and doing ultrasonography to measure the thickness of the skin folds of the neck of the fetus. If the results of the first-step tests indicate a high risk of those abnormalities in the fetus, the mother is offered further testing to detect abnormalities. These tests include a noninvasive prenatal test (NIPT) that evaluates the small amounts of fetal DNA that are released into the mother's blood, or an invasive test. Invasive tests directly test cells from the fetus using samples taken with a needle from the amniotic fluid (amniocentesis), placenta (chorionic villus sampling), or the umbilical cord. However, if the results of the first step of the sequential screen are low risk, the second step of the sequential screen is done later in pregnancy using a different set of blood tests to confirm the low risk status.

Magnetic resonance imaging (MRI) is now being used to further evaluate some abnormalities in the fetus that are first detected by ultrasonography. MRI may give additional information about an abnormality and can be useful in evaluating treatment options.

Fetoscopy is an invasive test in which doctors insert a small viewing scope (endoscope) into the womb. Early in pregnancy, the scope may be inserted through the mother's cervix. Later in pregnancy, the scope is inserted through a small incision in the mother's abdomen and then another incision in the uterus. The scope lets doctors take a direct look at the placenta and fetus to identify (and sometimes treat) disorders in the fetus.

Diagnosis after birth

After birth, nurses and doctors do a routine physical examination, measure oxygen levels in the blood, and do routine screening tests. Additional tests, including blood tests, x-rays, ultrasonography, and others may be done when babies have specific problems or have abnormal findings on the routine tests.

Depending on gestational age, newborns are classified as premature, late preterm, full term, late term, or postmature.

Newborns are further classified into three groups by how much they weigh compared to other newborns of the same gestational age. The three groups are

  • Small for gestational age (SGA): Less than the 10th percentile of weight, meaning they are among the 9 lowest-weight babies out of 100 born at a particular gestational age

  • Large for gestational age (LGA): Greater than the 90th percentile of weight, meaning they are among the 9 heaviest babies out of 100 born at a particular gestational age

  • Appropriate for gestational age (AGA): From the 10th to the 90th percentile of weight, meaning they are among the 82 babies in the middle range for weight

The gestational age and weight classifications help doctors determine the risk of various complications. For example, premature and late pre-term newborns are at increased risk of breathing problems because their lungs may not be fully developed. Large-for-gestational-age newborns may have more difficult births and be at increased risk of low blood sugar (glucose).

Treatment

Medical treatment of specific disorders is discussed elsewhere. When possible, the sickest newborns (neonates) are cared for in a neonatal intensive care unit (NICU).

Neonatal intensive care units (NICUs)

The NICU is a specialized facility that brings together the medical team and technology needed to care for newborns (neonates) with various disorders. Newborns may need such specialized care because of

The NICU team is typically directed by neonatologists (pediatricians specially trained to manage the problems of newborns). Much of the care is delivered by specialized neonatal nurses. Other team members may include pediatricians, neonatal nurse practitioners (advanced degree nurses specifically trained to manage newborns), neonatal physician assistants, respiratory therapists, social workers, pharmacists, physical and occupational therapists, speech-language pathologists, and other specialized personnel. Many NICUs also have doctors and students in training. Depending on the care required by the baby, medical and surgical subspecialist physicians are also often involved.

In the NICU, newborns are cared for in incubators or radiant warmers, which keep them warm while allowing staff to observe and treat them. Babies are usually connected to monitors that continuously measure their heart rate, breathing, blood pressure, and oxygen levels in the blood. They may have catheters placed inside an artery or in the vein running inside the umbilical cord to permit continuous blood pressure monitoring, to allow repeated blood sampling, and to give fluids and drugs.

NICU facilities vary widely. Some NICUs have wards in which many babies share a large space, some have modules with a few babies in a space, and some have private rooms for a family and their baby. Regardless of the layout, NICU personnel are focused on meeting the parents’ need for time and privacy to become acquainted with their newborn; to learn the newborn’s personality, likes, and dislikes; and ultimately to learn any special care that they will need to provide at home. Visiting hours vary but are usually flexible so that families can spend as much time with their newborn as they wish. Some hospitals have sleeping facilities for parents on-site or nearby.

Sometimes, parents feel that they have little to offer their newborn in a NICU. However, their presence, including stroking, speaking, and singing to their newborn, is very important. Newborns hear their parents' voices even before birth and are accustomed to them so they often respond better to their own parents’ attempts to calm them. Skin-to-skin contact (also called kangaroo care), in which the newborn is allowed to lie directly on the mother’s or father’s chest, is comforting to the newborn and enhances bonding.

Breast milk significantly reduces the risks of necrotizing enterocolitis (a serious intestinal disorder that can occur in premature infants) and infections in premature infants, and has a wide range of health benefits for all infants (see Benefits of Breastfeeding). NICU personnel strongly encourage mothers to breastfeed when their infant's condition permits. However, depending on their gestational age and medical problems, infants in a NICU may not be able to breastfeed or drink breast milk from a bottle. Premature infants are not able to suck adequately and are not able to coordinate sucking, swallowing, and breathing. Full-term infants in the NICU may have respiratory problems or other illnesses that make breastfeeding impossible. But, because breast milk is clearly the best food for newborns, mothers are encouraged to pump their breast milk for later use.

NICU personnel understand that parents need to be kept up to date on their baby's condition and expected course, the care plan, and the estimated time of discharge. Regular discussions with the nurses and medical team are beneficial. Many NICUs also have social workers who help communicate with the parents and assist in arranging family and medical services.

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Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • TYLENOL
  • No US brand name
  • DOLOPHINE
  • DEMEROL
  • DURAMORPH PF, MS CONTIN
  • OXYCONTIN
  • BUPRENEX
  • ACTIQ, DURAGESIC, SUBLIMAZE
  • DILAUDID