Neonatal unit Flashcards
What is a low birth weight?
Below 2500g
What is a very low birth weight?
Below 1500g
What is an extremely low birth weight?
Below 1000g
What is a neonatal death?
Baby born at 20 wks+ or with a birthweight of 400g or more (where an accurate estimate of gestation is not available) who died before 28 completed days after birth
What is an early neonatal death?
Baby born at 20 wks+ or with a birthweight of 400g or more who died before 7 completed days after birth.
What is a late neonatal death?
Baby born at 20 wks+, or with a birthweight of 400g or more who died from 7 -28 days completed days after birth
What is the difference between the resting posture of a term baby and a premature baby?
Term babies- lie with limbs flopping outwards, premature babies- limbs curve inwards. Babies become more flexed as muscle tone increases with advancing gestational age
What is a premature baby’s skin like?
Fragile, transparent skin. Skin becomes thicker, more opaque, and veins become less visible as gestational age increases
What is lanugo?
Soft, fine hair that is abundant over the body of the neonate from 20-28 weeks gestation, and declines as the infant matures. Most prevalent over the baby’s back, and retains the vernix caseosa on the surface of the skin. By term it has essentially disappeared
What is the difference between the plantar surface (sole of foot) of a premature baby and a term baby?
Premature- smooth until 28-30 wks, term- creased
What is the difference between the breasts of a premature baby and a term baby?
Premature babies born before 34 wks gestation exhibit barely visible nipples and areola; these babies also have no palpable breast
What is the difference between the ears of a premature baby and a term baby?
Cartilage formation in the ears and incurvature of the pinna generally occurs after 34 weeks gestation. Thus babies born prior to this will typically exhibit a flat, shapeless pinna, which lacks recoil when folded on itself and released
What is the difference between the eyes of a premature baby and a term baby?
Babies eyelids fuse at approx 9-10 weeks gestation, and do not fully open until the 26-28th wk. 23-27 wks, babies may vary between tightly fused (closed) eyelids, loosely fused (closed but separation can be achieved with gentle manipulation), and open eyelids
What is the difference between the genitalia of a premature baby and a term baby?
In male infants, testicular descent begins at approx 30 wks gestation, and both testicles should be palpable by 34 wks gestation; Rugae becomes more prominent as the scrotal sac thickens as gestation advances. In female infants, the labia majora and minora become more developed with advancing gestational age; at term the clitoris is completely covered
What are the features of an IUGR baby?
Relatively large head compared with whole body
Shrunken abdomen with “scaphoid” appearance (must be distinguished from diaphragmatic hernia)
Loose skin, sometimes dry, peeling, with the appearance of “hanging”, occasionally meconium stained
Long fingernails, especially in term and postterm infants with severe IUGR, occasionally meconium stained
Face with shrunken appearance or wizened
Widened or overriding cranial sutures, anterior fontanel larger than usual
Thin umbilical cord, sometimes meconium stained
Why might a baby be admitted to a neonatal unit?
Birth less than 37 weeks or more than 42 weeks
Birth weight less than 2,500 grams (5 pounds, 8 ounces) or over 4,000 grams (8 pounds, 13 ounces)
Small for gestational age
Medication or resuscitation in the delivery room
Birth defects
Respiratory distress including rapid breathing, grunting, or apnea (stopping breathing)
Infection such as herpes, group B streptococcus, chlamydia
Seizures
Hypoglycemia
Need for extra oxygen or monitoring, intravenous (IV) therapy, or medications
Need for special treatment or procedures such as a blood transfusion
Why do baby’s grunt?
Usually means they’re learning how to have a bowel movement. They haven’t yet figured out how to relax the pelvic floor while also using abdominal pressure to move stool and gas through their system. Their abdominal muscles are weak, and they must bear down with their diaphragm against their closed voice box (glottis). This leads to a grunting noise
Only ever happens on expiration- the air goes pass the epiglottis that has come down over their trachea so their next inspiration will be easier
Why is it concerning if a baby grunts?
Grunting paired with…blue tongue or skin, weight loss, fever, lethargy, nasal flaring, pauses in breathing, asthma, pneumonia, sepsis, meningitis, heart failure could be a sign of…
asthma, pneumonia, sepsis meningitis heart failure
A term baby will grunt when cold as it causes surfactant production to reduce
How might prolonged light exposure affect a premature baby?
Premature infants lack simple adaptive functions to assist in protecting their eyes from light. They have thinner eyelids than term neonates and adults. They have larger pupils as well as a decreased ability to constrict their pupils in response to light exposure at less than 30-32 weeks gestation Younger infants spend more time with their eyes open despite the intensity of illumination in their environment, can’t blink until 6 months old- stare a things that attract their attention for a long time, too weak to turn their head away Very low birth weight infants may therefore be uniquely susceptible to retinal damage from exposure to bright light. Can disturb their sleep and therefore the time they have brain development Pre-term babies are unable to deal with stresses of extraueterine life so are unable to self-console (bracing limbs, hand to mouth sucking, crying) and so demonatrate signs of negative response to stress (disruptions to vital signs, colour, tone, eye movements , frantic body movements, fixed positions, gaze aversion)
How could nursing staff minimise the effect of bright light in the NNU/SCBU?
not turning the lights on unless they are absolutely necessary incubator covers are used to reduce light exposure, thus encouraging good quality sleep.
What are the two ways sound can be heard?
Pitch (frequency) and loudness (decibels)
How might noise affect babies in NNU? How can noise be reduced?
Excessive auditory stimulation creates negative physiologic responses such as apnea and fluctuations in heart rate, blood pressure, and oxygen saturation. Preterm infants exposed to prolonged excessive noise are also at increased risk for hearing loss, abnormal brain and sensory development, and speech and language problems. Reducing noise levels in the NICU can improve the physiologic stability of sick neonates and therefore enlarge the potential for infant brain development. Recommendations include covering incubators with blankets, removing noisy equipment from the incubator environment, implementing a quiet hour, educating staff to raise awareness, and encouraging staff to limit conversation near infants.
What does evidence suggest is the greatest source of stress in a premature baby?
Touch signs of physiological instability (falling temperature and oxygen pressures, and increasing heart rates), preterm or unwell infants can express stress or pain through a number of well recognized signs or cue
What is the new ballad score?
A tool that estimates gestational age through the neuromuscular and physical assessment of the newborn infant. By confirming gestational age and growth patterns, paediatricians are able to appropriately identify babies that are at high risk of complications, and subsequently develop a suitable care plan
What disengagement cues or behaviours might you see in a stressed neonate?
Crying or fussing Gagging, spitting out Red eyebrows Frowning, grimacing Hiccoughing, yawning, sneezing Becoming red, pale or mottled Irregular breathing Jittery or jerky movements Agitated or thrashing movements Falling asleep Turning eyes, head or body away from you or the person who is talking Salute, finger splay Limp or stiff posture Back arching
What engagement cues might you see in a happy baby?
Eyes become wide open and bright as the baby focuses on you Turning eyes, head or body toward you or the person who is talking Alert face Healthy pink colour Steady breathing Hand-to-mouth activity, often accompanied by sucking movements Hands clasped together Grasping on to your finger or an object Smooth hand, arm, and leg movement Softly flexed posture (looks relaxed)]
What is NIDCAP (The Newborn Individualised Developmental Care and intervention Program)?
to promote emotional and cognitive growth and to maintain physiological wellbeing in babies in neonatal care encompasses environment, positioning, promotion of self regulation, handling and care giving - specifically it is an individualised care plan which aides the infant to accomplish developmental outcomes by reducing stress appear to show a reduction in intraventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD), and pneumothorax, and better weight gain and better outcomes at nine months post birth. Other studies have concluded that the model causes no harm
What are the three main positions that babies in an NNU/SCBU will be nursed in, and why?
babies typically have decreased muscle tone, which puts them at risk of developing postural problems if left in one position too long
What is the primary method of heat production (thermogenesis) in neonates?
preterm and low birth weight infants have much less ‘brown fat’ than full-term infants. Brown fat contributes to extra heat production. Adipose tissue (brown fat) or brown adipose tissue (BAT), is a special kind of highly vascular fat found in newborns. It contains an ample supply of blood vessels which cause the brown colour Some infants have insufficient brown fat stores. Preterm infants may be born before the stores of brown fat have accumulated. IUGR also depletes brown fat stores before birth occurs. Newborns that are exposed to prolonged cold stress may have insufficient brown fat stores as large amount brown fat is consumed for heat production in this situation. Thus, these infants will not be able to raise their body temperature if they are subjected to further episodes of cold stress. Without brown fat to be metabolized, no heat production will counteract the cold stress. Hence, the infant is at risk to serious complications
What are the four ways a baby can lose heat? And what are the effects of cold stress?
EVAPORATION – heat loss through wet skin CONVECTION – heat loss from cooler air circulating around warmer skin particularly when exposed CONDUCTION – heat loss through direct contact with a cold surface (e.g. scales, unwarmed mattress) RADIATION – heat loss from heat radiating towards a cooler surface (e.g. a cold window, wall or incubator wall) Cold stress can lead to harmful side effects within neonates,which include hypoglycaemia, respiratory distress(such as grunting, tachypneoa, and apnoea), hypoxia, metabolic acidosis, necrotizing enterocolitis and failure to gain weight
What is the normal temp for a neonate?
36.7-37.3
What is the thermoneutral environment?
Minimum metabolic rate and oxygen consumption to maintain a normal body temperature and normal activity Depends on the neonate’s birthweight, age and whether they are clothed or not
What are the 10 steps in the ‘warm chain’?
Warm delivery room Drying baby immediately Skin-to-skin contact Breast feeding Bathing and weighing postponed Appropriate clothing and bedding Mother and newborn together Warm transportation Warm resuscitation (newborns with asphyxia cannot produce heat effectively and therefore need to be kept warm) Training and awareness raising
What is a normal pulse in a neonate?
120-160
What is a normal BP in a preterm and term baby?
PT systolic , diastolic T systolic , diastolic
Average systolic BP is 60 to 80 mm Hg, and average diastolic BP is 40 to 50 mm Hg
What is a normal respiration rate in a neonate?
30-60
What is normal saturation in a neonate?
Term: 95-100
Pre-term: <36 wks 90-94
What is normal perfusion (capillary refill) in a neonate?
Up to 3 seconds
What is a normal blood sugar in a neonate?
d
What are the symptoms of RDS (respiratory distress syndrome)?
blue-coloured lips, fingers and toes rapid, shallow breathing flaring nostrils a grunting sound when breathing apnoea (stop breathing for >20 seconds and/or is accompanied by hypoxia or bradycardia) Recession ( ribs and centre of the chest pulled in- finding the work of breathing hard)
How might RDS be treated in the NNU?
oxygen ventilation artificial surfactant (lungs do not produce sufficient amounts of surfactant- keeps the tiny air sacs in the lung open) Intubated and given surfactant directly to lungs- from pigs- Muslims approve as don’t have to eat it
. As a result, a premature baby often has difficulty expanding lungs, taking in oxygen, and getting rid of carbon dioxide) (more effective if given at delivery) (Production begins 24-28 week)
What is hypoxia?
deficiency in the amount of oxygen reaching the tissues
What is ischaemia?
an inadequate blood supply to an organ or part of the body, especially the heart muscles.
What are the 3 categories of HIE?
mild severity - no long term major complications moderate - some problems, possibly affecting hearing, sight and motor skills severe - major complications or death Hypoxic (lack of oxygen) Ischaemic (restricting blood flow) Encephalopathy (affecting the brain)
What are the 2 stages of HIE?
1st stage: immediately after the initial oxygen deprivation. 2nd stage: occurs as normal oxygenated blood flow resumes to the brain- “reperfusion injury” and occurs as toxins are released from the damaged cells.
What could cause HIE?
placental insufficiency, uterine rupture, placental abruption, true umbilical knots, cord compression, maternal blood clotting disorders, fetal maternal hemorrhage, extremely low maternal blood pressure, trauma during delivery, placental blood clots, shoulder dystocia, cord prolapse, aneurysm rupture, cardiac arrest and near SIDS events.
What are the postulated mechanisms by which hypothermia is believed to be neuroprotective to babies?
Reducing the metabolism of the body systems allows [partial] recovery of some of the cells. Some of them are going to be damaged right away, and you cannot repair that damage. But other cells have a delayed damage that occurs from energy failure. The cells become swollen and burst, which causes an influx of electrolytes that you wouldn’t normally have; that causes additional cell swelling, which causes the cells to rupture. By applying the hypothermia, you can reduce not only the cell damage that occurs right away, but also the cell damage that occurs later. The cell walls are damaged, and it allows them to slowly repair themselves, to slow [both] the influx and the transition of these electrolytes (substance that produces an electrically conducting solution when dissolved in a polar solvent, such as water)so that, hopefully, we can preserve the cell membrane enough to recover. Therapeutic window: first 6 hours of life
What is apnoea of prematurity?
Respiratory problem in premature babies, two types: CENTRAL APNOEA: baby “forgets” to breathe, simply because the nervous system is immature OBSTRUCTIVE APNOEA: baby tries to breathe, but the airway collapses. Air can’t flow in and out of the lungs
What are the signs of hyperthermia?
Rapid breathing, rapid pulse, hot skin, red extremities due to vasodilation, flushed face, restless, crying, gradually becomes lethargic. Severe hyperthermia - shock, convulsions, coma
What are the signs of hypothermia?
Cold skin, lethargic, poor suckling, weak cry, slow/shallow/irregular breathing, slow pulse, low blood sugar, metabolic acidosis, internal bleeding (especially in lungs) respiratory distress
What is the warming procedure for neonates born before 30 weeks?
placed in a plastic bag or wrap at birth, with the head dried and a hat put on
What should incubator conditions be like?
Incubator care is most effective: environmental humidity of greater than 50% is required, up to 85% for extreme prematurity Central temperature should be maintained at 36.7-37.3°C, core peripheral difference 0.5-1°C
What is the metabolic triangle? And according to what it shows, what should we assess for in relation to cold stress?
Energy required for effective breathing- energy required to keep warm- energy required for adequate glucose homeostasis Since cold such stress can be associated with hypoglycaemia, increased oxygen demands and respiratory compromise, it is important to assess temperature, blood glucose and oxygenation together.
When can stabilised newborns be transferred from an incubator into an unheated bassinet or open cot?
Ideal weight of 1.6kg- then monitoring can move to intermittent observation of central body temperature and observational nursing
What is kangaroo care?
where neonates are held for a time on their parent’s skin before being returned to an incubator- the parent maintains the neonate’s body temperature in a neutral thermal environment
Why do preterm and low birth weight babies get cold?
Larger surface area ↓subcutaneous fat ↓brown fat ↑body water content Immature skin – evaporative heat loss Ineffective positioning ability Poor response to cold stress Unable to maintain peripheral vasoconstriction
RDS occurs in?
Predominantly premature babies Babies delivered by LSCS Monozygotic twins- identical -develop from one zygote,
What are the causes of LBW?
Uteroplacental failure Congenital infection (TORCH screening) Chromosome abnormality Smoking, drug abuse, alcohol abuse Malnourished mother
What is the metabolic triangle? And how does it explain how cold stress causes metabolic acidosis and causes RDS, hypoglycaemia and jaundice?
Respiratory rate increases in response to the increased need for oxygen.
In the cold-stressed infant oxygen consumption and energy are diverted from maintaining normal brain and cardiac function and growth to thermogenesis for survival. If the infant cannot maintain an adequate oxygen tension (measure of ‘how much’ oxygen there is pressure which oxygen in a mixture of gases would exert if it were on its own- Po2), vasoconstriction follows and jeopardizes pulmonary perfusion
As a consequence the Po2 is decreased, and the blood pH drops.
These changes can prompt a transient respiratory distress or aggravate existing RDS. Moreover, decreased pulmonary perfusion and oxygen tension can maintain or reopen the right-to-left shunt across the ductus arteriosus.
The basal metabolic rate increases with cold stress. If cold stress is protracted (lasting for a long time), anaerobic glycolysis occurs, resulting in increased production of acids. Metabolic acidosis develops; and, if a defect in respiratory function is present, respiratory acidosis also develops.
Excessive fatty acids can displace the bilirubin from the albumin-binding sites and exacerbate hyperbilirubinemia.
When an infant is stressed by cold, oxygen consumption increases, and pulmonary and peripheral vasoconstriction occur, thereby decreasing oxygen uptake by the lungs and oxygen to the tissues; anaerobic glycolysis increases; and there is a decrease in Po2 and pH, leading to metabolic acidosis.
Hypoglycemia is another metabolic consequence of cold stress. The process of anaerobic glycolysis uses approximately 3 to 4 times the amount of blood glucose, thereby depleting existing stores. If the infant is sufficiently stressed and low glucose stores are not replaced, hypoglycemia, which can be asymptomatic in the newborn, can develop.
Extra information from lecture
For every degree less than 36.5 the risk of sepsis is increased by 25%
Babies can be born cold if mum is really cold as her blood temp will drop
Cortisol levels reduces lactation
Use of domperidone- not always long lasting, increases lactation
1.2 kg at 28 weeks approx.
Low blood sugar- don’t have any reserves
Feeding- really hungry, the worry is due to lack of oxygen in utero gut has been neglected and so can’t deal with
Struggle with temperature control
Polycythaemic- too many RBCs, blood flow is sluggish, low blood sugar- not getting around fast enough
Mag sulphate- aids in brain development and reducing risk of cerebral palsy
