Lecture 10.1 - At Risk Newborn Flashcards
What are the three classifications of at risk NBs?
Birth weight, GA, common pathophysiological problems
What is considered a low birth weight?
< 2500 g
What is considered a very low birth weight?
< 1500 g
What is considered an extremely low birth weight?
< 1000 g
What is considered a preterm infant? What percent of births are preterm?
An infant born before 37 completed weeks of gestation, regardless of birth weight
8%
What is considered a late preterm GA? What percent of preterm infants are LPT?
between 34 to 36+6 weeks
–> 70% of preterm infants
What are some causes for indicated preterm birth?
Placenta previa/abruption
Pre-eclampsia
Poor fetal growth / IUGR
DM
Atypical / abnormal testing
What are some risks for spontaneous preterm births?
Hx
Multifetal gestation
Genital tract infection
Periodontal disease
Pow pre-pregnancy wt
Low SES
Lack of access to PNC
High stress
Smoking/substance use
What is the leading cause of neonatal and infant mortality?
Immaturity
What is the impact of neonatal complications on the family?
Loss of control + separation in NICU/special care causes interruption in attachment development
Greif over loss of healthy NB
Separation from rest of family/children
Late preterm babies are at increased risk for what complications?
Resp distress
Thermal instability
Hypoglycemia
Jaundice
Feeding problems
Neurodevelopmental issues
Infection
Preterm infants are at increased risk of having an ineffective breathing pattern/resp distress. Why is this?
Decreased number of functioning alveoli
Decreased surfactant - increased surface tension
Immature & fragile pulmonary vasculature
Decreased tracheal cartilage
What kind of monitoring should be done for a preterm newborn’s respiration?
VS, perfusion
Continuous SpO2
Obtain & monitor blood gas
Why can be done to manage periods of apnea in a preterm newborn?
Oxygen
Stimulation for wakefulness
Caffeine if necessary
What respiratory interventions are done for preterm infants?
Respond to apneic episodes/desats/brady
Oxygen:
- suction prn
- titration of O2
Surfactant replacement therapy
What are some complications of oxygen therapy that is too high?
Retinopathy
Intraventricular hemorrhage
Bronchopulmonary dysplasia
Not from slides:
Can impact hemodynamics of infants with congenital heart malformations
What is the O2 saturation goal for neonates?
93-95%
90-95% for ELBW
What factors increase the risk of ineffective thermoregulation for preterm infants?
Immature CNS control
Increased heat loss and inability to produce heat d/t less brown fat
Absent or decreased subcutaneous fat
What are some signs of ineffective thermoregulation?
Body temperature below 36.5°C
Cool, mottled, pale skin
Tachypnea, apnea, resp distress
Irritability, restless, agitated
Hypoglycemia
What is a neutral thermal environment?
Environment that maintains body temperature so that no energy is needed to do so.
What interventions can be done to maintain body temperature of infant?
Radiant warmer, isolette
Skin-to-skin, cap
Warmed, humidified O2
What monitoring or precautions might be done for an infant who is not thermoregulating?
A continuous temperature probe might be used
Use caution when weaning to a cot
What factors predispose a newborn to infection?
Immature immune system
Invasive procedures
What are some signs of infection in an infant?
Literally every single system might have changes + might look shocky or poorly perfused
Temperature instability - mostly hypothermia
Why are premature babies at an increased risk of NEC?
Immature digestive system + flora
Immature immune system
What factors put preterm infants at risk of imbalanced nutrition/less than requirements?
GI immaturity - adsorption
Decreased stomach capacity
Limited nutritional stores
Associated illness factors
Poor suck/swallow/breathe coordination
Resp distress
What are some signs of inadequate nutrition in a NB?
Inadequate weight gain
Feeding intolerance
PO feeding is always preferred for a NB is there is an adequate suck/swallow/feed/breathe reflex, and GI function and energy levels are good. What are some challenges to PO feeding?
Weak, uncoordinated, poorly developed reflexes.
Easily fatigues
Need to gain weight and have a small margin of weight loss
Issues with hypothermia can compound the problem
What are Gavage feedings?
Intermittent bolus/continuous feeding through NG/OG tube. Amount increases gradually and then eventual switch to PO.
Requires assessment if gastric residuals are > 50% of feed.
When would TPN be considered for a NB?
If they are too physiologically immature or seriously ill for enteral feeding
What are benefits of non-nutritive sucking?
Practice for premies + source of comfort
When an infant is hypoglycemic what other assessments should be performed?
Assess for physiological stress
Inadequate intake
Increased metabolic demands d/t illness or decreased glycogen supply
Inadequate gluconeogenesis
How long should we assess BGLs on a preterm infant?
for the first 36 hours if stable and feeding is established
What is the BGL goal for a NB?
> /= 2.6 mmol/L
What are some benefits of Kangaroo Care in the NICU?
Stable VS + oxygenation + thermoregulation
Improved sleep/wake cycles
Reduced pain
Facilitates BFing, increased weight gain attachment, and parental confidence
Which infants are more likely to have respiratory distress syndrome?
Preterm
To mothers with DM1
–> Increased insulin can inhibit surfactant production
By CS
–> Stress of birth releases glucocorticoids which increases surfactant production
What care is given to neonates with RDS?
Establish oxygenation & ventilation
Supportive care
–> Maintain neutral thermoregulation, perfusion, hydration
Surfactant replacement therapy
Antenatal betamethasone
What are some S/S of PDA?
Systolic murmur, active precordium, bounding pulses
Inspiratory crackles (pulmonary edema)
TachyTachy
How is PDA diagnosed?
X-ray, blood gases, echocardiography
Why are CS babies more likely to have RDS?
Less mechanical stimulation to clear amniotic fluid from lungs
Less release of endogenous glucocorticoids to increase surfactant productive
What is a post-term baby?
Born after 42 weeks regardless of birth weight
What risks are post-term infants at risk of?
Placental insufficiency
Increased O2 demands –> hypoxia
Meconium staining
Persistent pulmonary HTN of the newborn (PPHN)
What is PPHN?
Persistent pulmonary hypertension of the newborn is caused by persistent feta circulation d/t airways not opening well with meconium aspiration/resp distress
–> Critically ill with increasing hypoxia, pulmonary vasoconstriction, oxygenation failure
What is considered small for gestational age?
Birth weight that falls below the standard 10th percentile of sex-specific birth weight for GA
–> Not always pathological
What are symmetrical and asymmetrical IUGR?
Symmetrical
–> Starts in first trimester (infection, teratogens, chromosomal abnormalities)
–> All measurements below 10th percentile
Asymmetrical
–> Later onset due to maternal or placental factors
–> Head circ + length are above 10th percentile
What is considered LGA?
> 90th percentile for age and sex
What are some risks for SGA infants?
Perinatal asphyxia
Hypo/Hyperglycemia + insulin resistance leading to growth delay
Temp instability
Often tolerate feeds but run out of energy quickly
Developmental delay that may persist into school age
What risks of LGA infants predisposed to?
Birth injury, asphyxia, shoulder dystocia, hypoglycemia
What injuries are common in infants who experienced shoulder dystocia
Brachial plexus injury
Clavicle injury
What is a top priority for babies that are SGA or LGA?
Breastfeeding within first hour
How can we foster a nurturing environment in a NICU?
Quiet ambient sound - maximum decibel level of 45 dB
Clustering care
Covering isolettes with blankets for facilitate sleep/wake cycles
What can improve oxygenation in persistent pulmonary hypertension of the newborn?
Inhaled nitric oxide causes pulmonary vasodilation and reduces vascular resistance
