Birth Trauma

Infants who present with shoulder dystocia are at risk for clavicle fracture during delivery. The fracture is usually at the midclavicle and may first be noticed when the infant does

Box 22-5 Guidelines for Phototherapy in Hospitalized Infants >35 Weeks' Gestation (see Fig. 22-7)

0 12 24 36 48 60 72 84 96 108120132144

Postnatal age (hours)

Figure 22-6 Nomogram for designation of risk in 2840 well newborns at 36 or more weeks' gestational age with birth weight of 2000 g or more or 35 or more weeks' gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values. The serum bilirubin level was obtained before discharge, and the zone in which the value fell predicted the likelihood of a subsequent bilirubin level exceeding the 95th percentile (high-risk zone). This nomogram should not be used to represent the natural history of neonatal hyperbilirubinemia.

(From American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297-316.)


428 342

171 I 85

Birth 24 h 48 h 72 h

96 h 5 days6 days 7 days

Infants at lower risk (>38 wk and well) Infants at medium risk (> 38 wk and risk factors or 35-37 6/7 wk. and well Infants at higher risk (35-37 6/7 wk. and risk factors)

• Use total serum bilirubin (TSB). Do not subtract direct-reacting or conjugated bilirubin.

• Risk factors: isoimmune hemolytic disease, glucose-6-phosphate dehydrogenase (G6PD) deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis, or albumin <3.0 g/dL (if measured).

• For well infants at 35 to 37 6/7 weeks, can adjust TSB levels for intervention around the medium-risk line. It is an option to intervene at lower TSB levels for infants closer to 35 weeks and at higher TSB levels for those closer to 37 6/7 weeks.

• It is an option to provide conventional phototherapy in hospital or at home at TSB levels of 2 to 3 mg/dL (35-50 mmol/L) below those shown, but home phototherapy should not be used in any infant with risk factors.

Note: These guidelines are based on limited evidence, and the levels shown are approximations. The guidelines refer to the use of intensive phototherapy, which should be used when the TSB exceeds the line indicated for each category. Infants are designated as "higher risk" because of the potential negative effects of the conditions listed on albumin binding of bilirubin, the blood-brain barrier, and the susceptibility of the brain cells to damage by bilirubin.

"Intensive phototherapy" implies irradiance in the blue-green spectrum (wavelengths of approximately 430-490 nm) of at least 30 ^W/cm2 per nm (measured at infant's skin directly below center of phototherapy unit) and delivered to as much of the infant's surface area as possible. Note that irradiance measured below the center of the light source is much greater than that measured at the periphery. Measurements should be made with a radiometer specified by the manufacturer of the phototherapy system.

If total serum bilirubin levels approach or exceed the exchange transfusion line, the sides of the bassinet, incubator, or warmer should be lined with aluminum foil or white material. This will increase the surface area of the infant exposed and increase the efficacy of phototherapy. If the TSB does not decrease or continues to rise in an infant who is receiving intensive phototherapy, this strongly suggests the presence of hemolysis.

From American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297-316..

Figure 22-7 Guidelines for phototherapy in hospitalized infants of 35 or more weeks' gestation. For list of guidelines, see Box 22-5.

(From American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;1 14:297-316)

not move the arm on the involved side as much as the opposite arm. A fracture can also be detected when an asymmetric Moro reflex is found on neurologic examination. Most of these fractures heal rapidly and normally and do not require specific therapy.

Brachial plexus injuries usually result from pulling on the arm at delivery. Injuries can be caused by stretching of the nerve, hemorrhage within a nerve, or tearing of the nerve or nerve root. Erb's palsy is an upper brachial plexus (C5-6) injury that leads to adduction and internal rotation of the shoulder with resulting pronation of the forearm. Erb's palsy can also be accompanied by an ipsilateral paralysis of the diaphragm. Klumpke's palsy is a lower plexus

(C7-8 and T1) injury leading to paralysis of the hand and the wrist. Neither of these conditions is usually associated with demonstrable sensory loss more suggestive of a tear or avulsion. Both conditions usually improve rapidly, and in most patients, no deficits persist (Beers and Berkow, 1995). If a significant neurologic deficit persists for longer than 3 months, magnetic resonance imaging (MRI) may be helpful to determine the extent of injury to the plexus, roots, and cervical spinal cord.

Bleeding beneath the periosteum of the skull (cepha-lohematoma) is often seen with minor trauma sustained during labor and delivery. Cephalohematomas usually have a parietal location on the right or left side of the head and are unilateral in most cases. Treatment is not required, but the infant needs to be watched for signs of anemia or hyperbilirubinemia. Infants with a large cephalohema-toma are more likely to develop hyperbilirubinemia as the blood cells within the hematoma break down and are reabsorbed.

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