Pediatric Case Study: Myelomeningocele Diagnosis and Care

This case study centers on a 1-hour-old infant, Baby Girl, diagnosed with myelomeningocele, a neural tube defect. The assignment addresses the rationale for cesarean delivery in such cases, explains the pathophysiology of myelomeningocele using lay terms, and differentiates it from meningocele. It evaluates the father's understanding of the condition, identifies critical assessments, and details nursing interventions, including positioning, medication administration (hypertonic saline, antibiotics), physical therapy, and monitoring (FOC, oxygen saturation). The study emphasizes the importance of addressing hypoxia, providing parental education on infant handling post-surgery, and monitoring head circumference. The case study also includes a medication dosage calculation and references relevant research articles.

Running head: PEDIATRIC CASE STUDY
PEDIATRIC CASE STUDY
Name of the Student:
Name of the University:
Author note:

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Question 1
The case study demonstrate the prevalence of myelomeningocele in the concerned one
hour old infant, Baby Girl. Myelomeningocele is the name given to a tube of spina bifida –
neural tube defect, which is characterized by an incomplete formation of an infant’s spinal bones.
This results in the lack of closure of the spinal canal and back bone of the concerned child and
thus causes protrusion and exposure of the spinal nerves. Traditional repairing mechanisms used
for myelomeningocele form the rationale underlying caesarean delivery. Myelomeningocele can
undergo repair by facilitating a uterine incision, a procedure known as fetoscopic spina bifida
repair (Farmer et al., 2018). To perform the same, there is a need for the fetus to undergo
caesarean delivery – as observed in Baby Girl.
Question 2
The following lay language would be useful in educating the father on the
pathophysiology of myelomeningocele: When the mother is in her first month of being pregnant,
each of the two side of an infant’s backbone or spine join to cover and enclose the meninges,
spinal nerves and spinal cord. During this stage of development, the infant’s spine and brain are
called the ‘neural tube’. Any form of defect occurring to this neural tube at this stage is known as
spina bifida. Myelomeningocele is type of defect in the neural tube or spina bifida where the
backbones or the spinal bone of the baby do not form normally which leads to the formation of a
spinal canal which is incomplete. This will cause to the meninges, spinal nerves and spinal cord
to project out and be exposed from the back of the baby (Moldenhauer & Adzick, 2017).

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Question 3
Meningocele is different from Myelomeningocele with respect to symptoms and
deformities observed after the baby is born. An infant born with meningocele is found to possess
a sac filled with fluid present at open spinal gap. Myelomeningocele on the other hand is
considered to be one of the most severe forms of neural tube defects and is known commonly as
open spina bifida since the baby is born with an exposed or protruding spinal nerves, tissues,
meninges and spinal cord. Lack of mitigation of the same can result in adverse consequences like
hydrocephalus, impaired bladder control, latex allergy and tethering of the spinal cord (Peranteau
& Adzick, 2016).
Question 4
 Statement B: Such a statement in incorrect since lack of surgical repair of
myelomeningocele is likely to pave the way for complications in the affected baby such
as hydrocephalus, impaired bladder control, latex allergy and tethering of the spinal cord
which in turn can impair the baby’s ability to move or engage in physical activity
(Johnson et al., 2016).
 Statement D: Due to the spinal opening as well as wound due to surgical repair, there is
a need to maintain stringent standards of hygiene. Thus, in addition to simply maintaining
basic standards of hand hygiene, there is a need to frequently replace the surgical repair
area of the spinal opening with fresh and sterilized dressings. Additionally, spina bifida
has been evidenced to increase the risk of blister, burn, sore and callus development in
the lower extremities of the body. Thus parents must engage in frequent skin checks for
such injuries and also maintain strict hygiene standards to prevent any infections in
wound or skin areas (Heuer, Moldenhauer & Adzick, 2017).

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Question 5
One of the key abnormalities which can be observed from the above assessment is the
prevalence of bilateral clubfeet – a condition where the feet and soles of an infant protrude in a
downward direction and face inwards rather than outwards. While the exact cause has not
evidenced, the condition has been linked to infants born with deformities like spina bifida – as
observed in Baby Girl (Botelho et al., 2017). Additionally it can also be observed that Baby
Girl’s pulse rate is slightly higher than the normal values of approximately 120 to 160 beats per
minute and has also demonstrated no reaction in response to the oximeter. Additionally, Baby
Girl has also been found to demonstrate a pulse of 2+ indicative of a lower than normal or
diminished pulse. If left untreated, this may pave the way for speech or breathing difficulties in
an infant. Baby Girl has also demonstrated an FOC higher than the normal value of 34 to 35 cm,
thus indicative of hydrocephaly or cerebral edema (Yamashiro, Galganski & Hirose, 2019).
Question 6
1. The infant is kept in the prone position or on her back so as to minimize the risk of
inflicting any form of distension or pressure on the protruding spinal sac.
2. The infant with myelomeningocele is administer a hypertonic saline solution so as to
mitigate the complications of hydrocephalus or cerebral edema and water retention in the
brain.
3. There is a need to administer antibiotics intravenously to an infant with
myelomeningocele so as to reduce the risk of microbial infections which is likely to occur
as result of the spinal opening.

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4. Due to impaired motor skills and mobility within a baby with myelomeningocele,
administration of physical therapy based leg exercises will enhance skills of movement,
flexibility and strength in the legs.
5. The infant is to be placed in an incubator for warmth for the purpose of preventing
hypothermia.
6. The orthopedic consult will assist in monitoring limb strength in the infant as well as
decide upon surgical interventions to address the abnormalities of bilateral clubfeet.
7. The foley catheter will assist drainage of urine from the infant since minimal movement
is essential for her quick recovery after surgical treatment of the spinal defect.
8. The infant is devoid of any food intake orally (NPO) so as to prevent any gastrointestinal
discomfort which may affect post-surgical recovery.
9. Sterile gauze dressings are to be maintained with frequent replacement so as to prevent
microbial infections and facilitate recovery and wound treatment post-surgery.
10. FOC is measured for monitoring the prevalence of hydrocephaly which may be indicated
by a large head circumference (Kabagambe et al., 2018).
Question 7
 Strength of the solution (a): 140 mg
 Volume of the stock solution (b): 10 ml
 Strength of the solution (c): 100 mg/ml
 Volume of solution required to be drawn for this dose = a*b/c = 140*10/100 = 14 ml.
Question 8
One of the first issues to be addressed first is the treatment of the hypoxic condition of
the infant since it can be observed that the oxygen saturation of the infant has decreased to

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drastically and abnormally low levels of 71% as compared to normal ranges of 95 to 98%. To
prevent death as a result of hypoxemia, the baby must be immediately administered with oxygen
therapy using nasal prongs (Sims-Williams et al., 2017).
Question 9
The parents of the baby can be educated, with the help of simulation models, on the
correct way of holding their baby post the surgery. It will be advisable for the parents to ensure
that the baby lies in prone position for three to 6 days after surgery and avoid holding or cuddling
since this can result in fluid leakage from the area of incision near the spinal opening. After
wound healing, the parents may be advised to hold their baby only after following strict hand
hygiene, by placing arms on her head and below her pelvic region so as to prevent any suture
openings or microbial infections (Cherian et al., 2018).
Question 10
Even though as per the chart, Baby Girl’s FOC measures at the 95th percentile, which is
normal at birth, there is still a need to monitor the same. This is because a child’s head
circumference continues to increase till the next 2 to 3 hours or the next 36 months of life.
Continuous monitoring till the age of 3 will assist in determining any progression or deterioration
in Baby Girl’s growth (Lu et al., 2019).

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References
Farmer, D. L., Thom, E. A., Brock III, J. W., Burrows, P. K., Johnson, M. P., Howell, L. J., ... &
Management of Myelomeningocele Study Investigators. (2018). The Management of
Myelomeningocele Study: full cohort 30-month pediatric outcomes. American journal of
obstetrics and gynecology, 218(2), 256-e1.
Peranteau, W. H., & Adzick, N. S. (2016). Prenatal surgery for myelomeningocele. Current
Opinion in Obstetrics and Gynecology, 28(2), 111-118.
Johnson, M. P., Bennett, K. A., Rand, L., Burrows, P. K., Thom, E. A., Howell, L. J., ... &
Adzick, N. S. (2016). The Management of Myelomeningocele Study: obstetrical
outcomes and risk factors for obstetrical complications following prenatal
surgery. American journal of obstetrics and gynecology, 215(6), 778-e1.
Heuer, G. G., Moldenhauer, J. S., & Adzick, N. S. (2017). Prenatal surgery for
myelomeningocele: review of the literature and future directions. Child's Nervous
System, 33(7), 1149-1155.
Botelho, R. D., Imada, V., da Costa, K. J. R., Watanabe, L. C., Júnior, R. R., De Salles, A. A.
F., ... & Peralta, C. F. A. (2017). Fetal myelomeningocele repair through a mini-
hysterotomy. Fetal diagnosis and therapy, 42(1), 28-34.
Kabagambe, S. K., Jensen, G. W., Chen, Y. J., Vanover, M. A., & Farmer, D. L. (2018). Fetal
surgery for myelomeningocele: a systematic review and meta-analysis of outcomes in
fetoscopic versus open repair. Fetal diagnosis and therapy, 43(3), 161-174.

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Sims-Williams, H. J., Sims-Williams, H. P., Kabachelor, E. M., Fotheringham, J., & Warf, B. C.
(2017). Ten-year survival of Ugandan infants after myelomeningocele closure. Journal of
Neurosurgery: Pediatrics, 19(1), 70-76.
Cherian, J., Belfort, M. A., Shamshirsaz, A. A., Espinoza, J., Olutoye, O. A., Cass, D. L., ... &
Whitehead, W. E. (2018). Two-Port Endoscopic Fetal Closure of
Myelomeningocele. Videoscopy, 28(3).
Lu, V. M., Snyder, K. A., Ibirogba, E. R., Ruano, R., Daniels, D. J., & Ahn, E. S. (2019).
Progressive hydrocephalus despite early complete reversal of hindbrain herniation after
prenatal open myelomeningocele repair. Neurosurgical focus, 47(4), E13.
Moldenhauer, J. S., & Adzick, N. S. (2017, December). Fetal surgery for myelomeningocele:
After the Management of Myelomeningocele Study (MOMS). In Seminars in Fetal and
Neonatal Medicine (Vol. 22, No. 6, pp. 360-366). WB Saunders.
Yamashiro, K. J., Galganski, L. A., & Hirose, S. (2019, August). Fetal myelomeningocele repair.
In Seminars in pediatric surgery (Vol. 28, No. 4, p. 150823). WB Saunders.