HIGH RISK NEWBORN

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HIGH RISK NEWBORN
Lecture 13
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LEVELS OF NICU

• Level I
• Basic neonatal care minimum requirement for a
  facility that provides inpatient maternity care.
• Able to perform neonatal resuscitation.
• Evaluate healthy newborns provide standard care.
  
• Stabilize newborns til transfer to intensive care
• Level II AKA Special Care Nurseries
• Basic care to moderately ill infants 32 42
  wks.
• Step down from level III NICU infants recover
• Level III
• Newborns lt32 wks, critical illness, needing
  surgical intervention. RNs - intensive
  training 6-8 mos.

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• National studies show
• 30 survival rate for 23 wk preemies.
• 52 for 24 wks.
• 76 for 25 wks.
• African American women twice as likely to
• deliver early, but babies more likely to survive.
• High risk newborns in NICU
• Use cardiac apnea monitors radiant warmers O2
  sat, VS, BP monitoring.
• Assessed q 1-2 hrs. or continuously
• risk of infections GBS, septicemia, thrush
• Moms encouraged to visit NICU daily
• Skin care to prevent breakdown.
• Good hand washing - parents/staff.

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• RDS Pre-Term
• Resp.distress syndrome aka hyaline membrane
  disease
• In preemie, insufficient surfactant in alveoli
  causing lungs to collapse not enough O2.
• Most common disorder of preemies.
• resistance causes fibrous tissue in bronchioles
  alveoli
• poor O2/CO2 exchange.
• Self-limiting 72-96 hrs in most late preterm
  or full term.
• VLBW (ELBW) - RDS can persist days/weeks. D/T
  immature lungs, non-compliance, and low
  surfactant levels.

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Causes of RDS - Term

• In term infant
• Sepsis GBS
• Persistent Pulmonary Hypertension of Newborn
  (PPHN) ductus arteriosus does not close.
• Meconium aspiration r/t oligo, uteroplacental
  insufficiency, fetal distress
• Infants of diabetic moms.
• May need resuscitation _at_ birth.
• In Pre-term infant Immature lungs,
  non-compliance, low surfactant levels.

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• S/S of RDS (In PRETERM)
• Retractions - drawing back of chest muscles with
  breathing. Infant works harder at lung expansion.
• SOB and expiratory grunting self-induced by
  infant - maintains pressure in lungs by causing
  expiratory braking using vocal cords (glottis
  partially closes increasing alveolar surface
  tension)
• Nasal flaring TTN transient tachypnea 60
  R/min.
• Management
• ABGs, O2 sats, CBC, bl.cx
• Skin/mouth care
• Suctioning (prn)
• Support for family
• Adequate fluids and electrolytes
• Replace surfactant Curasurf man made ET tube
• O2 therapy Oxyhood CPAP ventilator CPAP
  cont. airway pressure helps keep small air sacs
  from collapsing suction prn

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Terms AGA - Approp.
for gestational age 5.7 9.1 SGA - Small for
gestational age. lt 5.7 lbs. LGA - Large for
gestational age. gt 9.1 lbs.
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• SGA weight lt 10th percentile compared to others
  of
• same gestational age. 38 wk. weighs 5 lbs.
• Aka IUGR aka Failure to thrive.
• Most common cause placental anomaly placenta
  not receiving sufficient nutrition from uterine
  arteries or placenta.
• Severe DM, pre-eclampsia, poor nutrition,
  smoking, cocaine. Decreases blood flow to
  placenta.
• Fundal height lower than expected for gest.age.
• Bio Physical Profile assesses placental
  function.
• If infant not thriving in utero, will do C/S
  weigh pros/cons.

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• SGA infant wasted look, dull hair, small liver
  bilis, poor skin turgor, low glucose, low
  temp.
• Mature neuro responses, sole creases, ear
  cartilage.
• Lab findings HCT low plasma levels RBC
• polycythemia Causes thicker blood making heart
  work
• harder chance of thrombosis. Prolonged
  acrocyanosis.
• Manage fluids freq.feedings.

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LGA aka macrosomic infant. gt 90 percentile.
Appears healthy may be gestationally immature
immature neuro responses respiratory effort.
Assess larger than average uterine size for
gestational age Do sono to estimate size. Check
dates. C/S for CPD or shoulder dystocia.
Causes GDM, omphalocele, transposition great
vessels. Appearance possible fx clavicles
facial/head bruising, facial/neck palsy, caput,
cephalohematoma. Observe hypoglycemia,
polycythemia, irregular HR, cyanosis in
transposition
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Preterm Infant

• 90 term births full-term 11 preterm lt 37
  wks
• Calculated by gestational age not weight.
• Maturity determined by physical findings sole
  creases, skull firmness, ear cartilage,
  neurologic findings pregnancy dates.
• SGA Pre-terms 2 different causes w. diff.
  problems.
• Preterm fetus has been doing well in utero but
  trigger initiates labor infant is born early.
• Problems poor thermoregulation, hypoglycemia,
  intracranial bleed, RDS, NEC, immature kidney
  function, infection.
• 80-90 of infant mortality in 1st yr. life esp.
  VLBW infants

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• Risk Factors of Preterm Delivery
• Women of middle/upper socioeconomic 4-8
• Lower socioeconomic levels 10-20
• Inadequate nutrition lack of money knowledge
  about good nutrition lack of support.
• American Academy of Pediatrics live-born infant
  weighing 2500 g. or less.
• World Health Organization (WHO) American
  College of Obstetricians and Gynecologists (ACOG)
  both define it as infant born prior to 37 wks.

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Appearance of Preterm Infant
24-36 weeks

• Small, underdeveloped, head disproportionately
  large skin thin ruddy little subcut. fat
  veins noticeable prolonged acrocyanosis. vernix
  depends on gest.age.
• lt 24 wks.vernix not formed.
• None/few sole creases.
• Ear cartilage immature no quick rebound of
  pinna.
• Extensive lanugo.
• Suck/swallow absent, weak cry lt 33 wks. Ballard
  Gestational scale to estimate age.
• Infection decreased maternal antibodies
• Skin fragile limit alcohol rinse with water.
  Adhesives cause skin tearing. Use skin barriers
  to protect skin. Tegaderm tape. Handwashing a
  must !

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Former Extreme Premature Teen

• 13 year old female
• Ex-24 week preemie
• BPD, trach/vent
• 15 mos in NICU
• G-tube 3 yrs
• Decannulated at age 4
• Intensive learning support
• Eating age-typical diet
• Mild articulation errors

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• Thermoregulation
• risk for hypothermia r/t large surface in
  relation to body weight.
• Limited stores of brown fat
• Decreased or absent reflex control of skin
  capillaries
• Immature temperature regulation in brain
• Kangaroo care skin to skin contact
• Assess Respiratory Effort
• May need intubation to maintain respirations.
• lt 32 wks irregular respiratory pattern normal
• Survanta in ET tube

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Urinary/Elimination

• Have high insensible water loss d/t large body
  surface compared w/ total body weight. Lower GFR
  d/t immature kidneys. Fluid overload or
  dehydration.
• Strict I/O
• Immature kidneys secrete glucose slowly gt
  hyperglycemia can result.

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Insensible Water LossApprox. water loss in
body

• Age group Water
• Premature infant 90
• Newborn infant 70-80
• 12-24 months 64
• Adult 60

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• Nutrition promote normal growth development
• Tries to maintain rapid rate of intrauterine
  growth.
• Lack of cough reflex can aspirate formula.
• Have weak sucking, swallowing, gag reflexes
• Weak abdominal muscles weak gag reflex
• aspiration risk
• BMR - High caloric needs but small stomach
  capacity
• Limited store of nutrients
• Decreased ability to digest proteins and absorb
  nutrients, and immature enzyme systems.
• TPN, PPN, Gavage, or IV feedings

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• Feeding
• Caloric requirement PT 95-130 kcal./kg/day.
• Term infant 100-110.
• Smaller stomach capacity sm.,freq. feedings q
  2-3 hrs.
• Formula Calories for premie 24 cal./oz. Term
  20 cal/oz.
• Breast milk good d/t immunologic properties.
• Gavage nasogastric/orogastric. Gag reflex not
  intact til infant 32 wks avoid over filling
  stomach may cause respiratory distress. Use
  premie nipple.

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Developmentally Supportive Activities (new)

• Kangaroo Care/Skin to Skin Care
• Non Nutritive Sucking (Significantly reduced
  length of hospital stay for preterm infant)
• Non Nutritive at the Breast (pacifer)
• Parent Education Support

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Non-Nutritive Sucking at Breast

• Improved milk production
• Provides sucking experience
• Prepares infant for breastfeeding
• Long term effects
• Increased length of exclusive breastfeeding
• Increased length of total breastfeeding

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POTENTIAL COMPLICTATIONS of PT Infant
Anemia of Prematurity red blood cell life is
short. Low bone marrow prod. until 32 wks.
Frequent blood testing. Kernicterus destruction
of brain cells by invasion of indirect bilirubin
bili 20. PT infants low serum albumin
available to bind indirect bili excrete
it. Persistent Patent Ductus Arteriosus d/t
hypoxia, lack of surfactant, lack of
musculature. Lungs are noncompliant. blood
stays in pulmonary artery gt pulmonary artery HTN
gtpersistent PDA. Indocin stimulates PDA
closure.
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• Bronchopulmonary Dysplasia. (Chronic Lung
  Disease)
• Results from long term O2 being vented (PPV).
• Lungs immature resp.infection, poor nutrition,
• Pressure damages stretches lung tissue results
  in airway
• edema fibrotic buildup. Alveolar walls thicken
  buildup of
• secretions pneumonia atelectasis possible.
  Decreased
• oxygenation results.
• S/S tachypnea, tachycardia, hypoxia, grunting,
  retractions, feeding activity intolerance.
• TX prevent further disease promote oxygenation,
  promote lung healing.
• O2, nutrition, steriods, bronchodilators,
  diuretics, antibiotic tx stop PPV maintain
  venting _at_ lowest pressure.
• Nitric oxide Vitamin A

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Neonatal Sepsis

• Premies more susceptible immature immune sys.
• Transmission viral, bacterial transplacental
  (syphilis, toxoplasmosis)
• S/S low temps, resp. distress, hypotension, HR,
  RR, lethargy, poor feeding, diarrhea, vomiting.
• Mortality 5-20
• CBC with diff (bands, decreased neutrophils,
  decreased platelets), blood cx,
• TX broad spectrum antibiotics VS, nutrition,
  fluids, O2. Parental support.

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• ROP Retinopathy of Pre-maturity.
• Caused by damage to immature blood vessels in
• retina. Results in scarring. Caused by high O2
  levels.
• Blindness may result. 90 of cases no impairment.
  
• Occurs in VLBW lt1500 g.
• TX reattachment of retina Frequent eye evals.
  Laser to reduce scarring.
• Nursing Care routine high risk premie care
  sepsis VS support groups education

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• Intracranial Hemorrhage aka IVP
• germinal matrix made up of fragile vascular
  capillaries. Grades 1-4 (3 4 worse)
• Bleeding into ventricles d/t hypoxia, BP,
  fluids.
• Dx with Cranial ultrasound
• Normal brain function assessed gt bleed.
• IVH occurs in 20-25 of VLBW premies suffer more
  severe grades of IVH
• IVH is an important predictor of adverse
  neurodevelopmental outcome
• ½-3/4 of infants with Grade 3-4 IVH develop CP
  75 in some type of special education

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NEC

• NEC necrotizing enterocolitis common in PT
  baby
• can result in ulcers/tissue necrosis in
  intestinal wall.
• Bacteria in bowelgtinfectiongtdestroys bowel
  tissuegt
• sepsis.
• Primary risk factor prematurity tube feedings
  
• RDS, congenital heart defects.
• S/S abd. swelling, septic infant, emesis, blood
  in stool.
• Tx stop tube feedings, start IVF TPN, AB
  sepsis,
• ventilator, platelet transfusion control
  bleeding
• Prevention Delayed /Slow feedings advance lt 20
  ml/kg/day Enteral Antibiotics Antenatal
  Steroids enteral IgG, IgA Human Milk Feedings.

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• GDM
• Infants GDM moms macrosomic if not well
• controlled during pregnancy lethargic d/t
  glucose.
• Macrosomia overstimulation of pituitary growth
• hormone in fetus in preg. d/t maternal insulin.
  
• Mom insulin resistant glucose x placenta
  more insulin made by fetal pancreas.
• After delivery, glucose levels drop, but insulin
  remain for several hours.
• Infant jittery on admission. Glucose checked
  for 1st
• 4 hrs Hypoglycemia lt 40 mg/100 ml whole
  blood.

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GDM Complications Immature lungs d/t fetal
insulin which interferes with cortisol release
blocks formation of lecithin prevents lung
maturity. chance of birth injury d/t size
shoulder dystocia. Hypoglycemia Check glucose
on admission to NBN 1, 1½, 2, 4 hrs. of life.
If lt 40 stat serum glucose feed formula 1/2
oz. Repeat in ½ - 1 hr. as protocol.
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• Transient Tachypnea of Newborn TTN
• Rapid, shallow RR 70-80/min. d/t slow absorption
  of lung fluid.
• Difficulty feeding infant will not suck d/t
  rapid breathing.
• Chest x-ray shows fluid in lungs.
• Infant must resp.depth to aerate effectively.
• Can signify obstruction. VS, O2 sat give O2.
• Send to NICU for close observation if not
  resolved within 4-6 hrs.of life.
• Occurs more w. term C/S preterm infants.

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• Meconium Aspiration Syndrome
• Present in fetal bowel as early as 10 wks. Infant
  may aspirate meconium in utero or with 1st
  breath.
• Can cause severe respiratory distress,
  inflammation or blockage of small bronchioles by
  mechanical plugging
• Ductus arteriosus may remain open causes blood
  to shunt from pulmonary artery to aorta instead
  of passing thru lungs pulmonary resistance,
  causing hypoxia.

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Symptoms

• Tachypnea RRgt60
• Retractions
• SOB and expiratory grunting
• Nasal flaring
• Periods of apnea
• Bluish color of skin and mucus membranes
• Arms or legs puffy or swollen
• Prevention
• Oropharyngeal suctioning of infant gt delivery
• Laryngoscopic visualizaiton of vocal cords gt
  intubation.
• Additional suctioning of trachea.
• Amnioinfusion dilutes meconium. Thins out
  particulate meconium. Do sepsis workup CBC,
  bl.cx., chest x-ray. AB therapy to prevent
  pneumonia.

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• SIDS sudden infant death syndrome.
• Mainly in adolescent moms, closely spaced
  pregnancies, underweight, PT infants. 2nd hand
  smoke.
• Appear well nourished. African American males.
• Silent death poss.laryngospasm.
• Use of sleep apnea monitor for first few
  wks.-mos. Peak age 2-4 mos. Cause unknown.
• Theories HR abnormalities, decreased arousal
  moro
• responses, prone position, low surfactant, brain
  stem
• abnorm.
• In 2000 Amer. Academy of Pediatrics recommended
• back or side position not prone. Incidence
  declined 50
• since then. New data use of pacifier for 2-4
  mos.

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• Hyperbilirubinemia
• levels of unconjugated (indirect) bilirubin in
  blood. Breakdown of RBCs gt Hgb gt heme gt
  Unconjugated bilirubin.
• Bilirubin binds with plasma protein (albumin)
  bound goes to liver converts to conjugated or
  H2O soluble where it s excreted via bile by
  feces.
• Immature livers which cannot convert indirect to
  direct indirect bilirubin remains in
  bloodstream.
• Unbound bilirubin (indirect) jaundice.
• If indirect level rises gt 7, yellow color
  results.
• Sclera, nail beds, then skin.
• Cephalocaudal progression head to toe.
• Blanch skin
• Depends on hours/days of life.
• Younger infant (4-5 hrs.) high reading more
  significant could rise steadily .
• Older infant (1-2 days), higher less
  significant (more mature liver).

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• Pathologic within 24 hrs.
• Bili rises quickly. By 5-7 mg/dl/day or more.
• Blood type incompatibilities sepsis birth
  trauma.
• Interventions Early frequent feedings to
  speed up excretion in stool.
• Phototherapy - bilirubin becomes water
  soluble to be excreted.
• Cover genitalia eyes. Prevent organ damage.
  Single, double, triple phototherapy.
• Kernicterus Indirect bilirubin of 20 gt permanent
  brain damage bilirubin encephalophathy.
• Signs hi-pitched cry, seizures, hypotonia
• Interventions Immediate exchange transfusion
  followed by phototherapy frequent bili levels.

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• Physiologic Jaundice gt 24 hrs. 2nd-3rd day.
• R/T low albumin (decreased binding sites for
  bilirubin). levels of RBCs. Yellowing of skin
  caused by breakdown of fetal red blood cells
  which produces excessive amts. of bilirubin in
  blood stream. Excess bilirubin in blood causes
  jaundice.
• Management frequent feedings, frequent bili
  levels. Bili declines within days.
• Teach parents to place near window to speed up
  breakdown of bili. Sunlight will breakdown.

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• Gastroschisis weakness in abdominal wall
• causing herniation of gut on umbilical cord
• during early development most commonly on
• right side. Viscera lie outside abdominal cavity
  
• not covered with sac.
• 1 in 4,000 live births
• Mortality 10-15
• Assoc.w.prematurity malrotation of intestines
  decreased abdominal capacity other anomalies
  rare.
• TX IV NG tubes immediately TPN Silastic
  (synthetic covering) over viscera surgical
  closure after contents returned to abd.cavity. If
  necrotic bowel present, remove.

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• Nursing Care
• thermoregulation (monitor temps, radiant warmer)
  sterile technique (cover viscera - warm, sterile,
  saline gauze plastic) monitor VS, color, etc.)
  strict IO, daily weights, fontanels, pacifier,
  electrolytes. Minimize movement of area.
• encourage bonding asap developmental stimulation
  for long term hosp support group for parents
  teach parents s/s bowel obstruction- ie.
  vomiting, pain, firm abdomen, anorexia,
  irritability.

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• Omphalocele large herniation of gut into
  umbilical cord. Viscera outside of abd.cavity
  covered with peritoneal amniotic membranes
• 1 in 5,000 to 10,000 live births
• Assoc.w.malrotation of intestines decreased
  abdominal capacity. Stenosis common cardiac,
  genitourinary, or chromosomal anomalies common
  (1/3 to ½ of cases)
• Mortality 20-30 sepsis intestinal
  obstruction.
• TX same as for gastroschisis
• Nursing Care Same as for gastroschisis.

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Bladder Exstrophy extrusion of urinary bladder
to the outside of body through developmental
defect in lower abdominal wall. Assoc.w.genital
anomalies wide symphysis pubis. Rare
congenital anomaly bladder is turned inside
out TX protect exposed bladder tissue cover
with saline gauze/plastic wrap til sugery.
Prevent UTI. Reconstruction of bladder
genitalia. Provide support education
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• EA (esophageal atresia) TEF (tracheo-esophageal
  fistula)
• Cause unknown.
• Congenital malformations esophagus ends before
  reaching stomach. (TEF) fistula may connect to
  trachea.
• 1 in 2,000 - 4,500 live births. 30-50 have other
  anomalies (cardiac, GI, nervous sys).
• Premature or LBW common
• EA without TEF Inability to pass suction or NG
  tube catheter _at_ delivery. Confirm with
  abd.x-ray Excessive oral secretions vomiting
  risk of aspiration Abdominal distention
  Airless/sunken abdomen.
• Hx maternal polyhydramnios
• TEF without EA food enters trachea choking
  cyanosis.

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Statistics

• Esophageal atresia with distal TEF 87Isolated
  esophageal atresia without TEF 8Isolated TEF
  4Esophageal atresia with proximal TEF
  1Esophageal atresia with proximal and distal
  TEF 1

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Management infant supine w. HOB to decrease
secretions. NG tube for frequent suctioning to
prevent aspiration of gastric secretions IVF
assess VS, resp.distress, measure abd.girth
provide education support to family. Surgical
repair fistula ligation end to end anastomosis
of atresia. Provide post op care. IVF, G-tube
foley care pain VS, IO, skin care.