The High-Risk Newborn: Problems Related to Gestational Age & Development Flashcards
Approximately 9% of all newborns are sick enough at birth to require special or intensive care
Preterm Infants
- Preterm, or premature
! Review safety alert boxes in textbook
Appearance
* Small size
* Unflexed posture
* Red skin
* Abundant vernix and lanugo
* Immature ears
* Immature genitals
* Have very delicate skin that is very fragile and easily damaged
Thermoregulation
* Increased risk of cold stress
- Due to thin skin
- Blood vessels are closer to the skin surface
- More likely that cooling can occur
- Also little, if any, subcutaneous fat has developed
- Large surface area exposed due to lack of flexion
- Have an immature temperature control center so their ability to manage their temperature is nonexistent at this point
* Maintain a neutral thermal environment
- Keep them dry
- Prevent drafts
- Use warmed O2
- Keep incubator doors closed; ensure a warm environment for them
- Dressed, wrapped, and wearing a hat when taking them out (they’ll wear the hat for about 6 months compared to the term infant)
* Increase of insensible water loss due to difficulty maintaining fluid balance
- Through sweating, the lungs
- Carefully monitor I+O
- The kidneys don’t concentrate or dilute urine as well as a term infant
Pain
* Greater risk of ineffective pain management
* Interventions include:
- Comfort measures
- Containment or swaddling
- Pacifier
- Sucrose
- Breastfeeding
- Kangaroo care
- Analgesic medication if needed
Respiratory
* Decreased ___ production (leads to signs of respiratory distress)
* Risk of ___ (due to continued pressure airway ventilation)
* Poor cough reflex (gagging reflex)
* Narrow respiratory passages
* Weak respiratory muscles
* Prone positioning
- To help decrease the breathing effort and help increase their oxygenation while getting them to breathe better
- As soon as we can, get them into the supine positioning
! If a baby grunts, that’s an early sign of respiratory distress
surfactant
atelectasis
Oxygenation
Oxygen hood: infant can breathe on their own, but need extra oxygen supply
Nasal cannula: infant can breathe on their own, less supplemental oxygen needed
___: infant is needing help - keeps the alveoli open and improves the expansion of the lungs
> Helps remaining fetal lung fluid to absorb
> On temporarily and then transition off to nasal cannula or O2 hood
> Note: room air (RA) is 21% O2
CPAP
Oxygenation cont’d
Mechanical ventilation: when respiratory failure, severe apnea, or bradycardia occur
> When baby intubated
> Have severe respiratory failure, severe apnea, or are experiencing bradycardia in addition to their respiratory condition
> Oxygen should be moistened and heated to prevent cold stress and insensible water loss
Infection
* Preterm infants are at greater risk of infection development
* They lack the same passive antibodies as full-term infant
> Didn’t have as much time in utero to receive as much of those antibodies to cross placenta
- Breastfeeding not as effective just yet
* Immune system is very immature - unable to fight off infection [can’t localize infection]
* Fragile skin = increased risk of broken barrier for infectious pathogen
* Preterm infants have more invasive procedures than the term infant
Overstimulation
* Preterm infants are more sensitive to noise and touch (as they should still be in utero at this point)
* Too much stimulation around them can cause negative effects
* Oxygenation changes
* Behavioral changes (more fussy)
* Allow for quiet rest periods
* Keep noise in the area at a minimum (goal is 30 decibels)
* Teach parents the signs of an overstimulated infant
Nutrition
* Preterm infants need increased nutrients because they lack nutrient stores
* Poor feeders - lack suck/swallow coordination and fatigue easily (burn energy quicker)
> Be bottle, tube, or syringe fed
> Have smaller mouths
* Gavage feeding (have an NG tube in place)
* Signs preterm infants are ready for nipple feeding (via bottle or breast):
> Rooting
> Sucking on gavage catheter or pacifier while feeding
> Positive gag reflex (food is going to the right place and not the lungs)
> Respiratory rate is less than 60 breaths per minute during feed (if >60 won’t be able to tolerate nipple feeding yet)
* Teach mom to pump and store breastmilk
Parent Teaching
* Provide information about infant’s condition and characteristics
* Orient to special care nursery (SCN) or neonatal intensive care unit (NICU)
* Explain the various equipment and its use, as well as normal and abnormal sounds
* Involve the parents in infant care activities, letting them take over when able
* SPEND TIME WITH THE PARENTS
* Begin preparation for discharge early
___ ___ Infants
* Born between 34 weeks and 36 weeks, 6 days (before the 37th week mark)
* May have more of the appearance of a term infant but have all the needs of the preterm infant so we treat them based on their gestational age over their appearance
Late Preterm
Late Preterm Infants
* Account for 70% of all preterm births
* Contributing factors;
- difficulty estimating gestational age
- multifetal pregnancies
- obesity
- assisted reproductive technology
- induction of labor
- cesarean deliveries
- advanced maternal age (placenta doesn’t work as effectively) and
- normal causes of preterm labor/birth
* At risk for;
- respiratory disorders (and distress at delivery)
- problems with temperature regulation
- hypoglycemia
- hyperbilirubinemia
- feeding difficulties
- acidosis and
- sepsis because of immaturity (due to increased risk of infection and inability to localize infections)
Nursing Considerations
* Thermoregulation
- Prevent unrecognized cold stress - assess temperature every 3-4 hours
- Kangaroo care, radiant warmer, or incubator may be needed if the infant cannot maintain temperature
* Feeding
- Most common reason for hospital readmission → poor feeding
- Immature suck and swallow reflexes; missing gag reflex
- Low tone, weak suck = poor exchange of breastmilk
- Feeding problems are common. Monitor I+O closely before and after feed
- Lactation consultants should be involved
- Could sleep during feeding → need to wake them up
Nursing Considerations cont’d
* Discharge
- Do not discharge before 48 hours of age
- Car seat challenge test - to maintain oxygenation
- Teach signs of overstimulation and how to minimize them
- Normal vital signs 24 hours
- Bilirubin levels within normal range
- Follow-up with pediatrician in 24-72 hours of discharge
! Educate parents on signs of jaundice and dehydration
> These will often go hand-in-hand
- Eat to excrete; eat to be hydrated (breastmilk) which will promote excretion of meconium and that’ll help reduce the risk of jaundice
Common Complications of Prematurity
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Caused by insufficient surfactant in the lungs (which is usually sufficient at about 34-36 weeks gestation)
* Primary cause is ?
Risk factors include asphyxia, cesarean delivery, multiple births, male infants, cold stress, and maternal diabetes
Less common in the setting of chronic fetal stress, such as heroin addiction, maternal hypertensive issues, prolonged rupture of membranes, or following antenatal corticosteroids
If too little surfactant, the lungs and thorax become noncompliant, or “stiff,” and resist re-expansion - causing the infant to exert much more energy to breathe and severe retractions (see ribcage outline)
As fewer alveoli expand, atelectasis, hypoxia, and hypercapnia occur, leading to pulmonary hypertension
> Will reopen the ductus arteriosus; blood won’t go to the lungs to be oxygenated
Respiratory Distress Syndrome
prematurity
Respiratory Distress Syndrome - Symptoms & Management
Symptoms [worsens around 3 days of life and gradually improves]
- Tachypnea
- Nasal flaring
- Retractions
- Cyanosis
- Grunting
- Breath sounds decreased
- Rales
- Acidosis
Management
- Surfactant replacement therapy (administer synthetic surfactant directly into the lungs)
- Oxygen
- CPAP
- Mechanical ventilation
- Inhaled nitric oxide therapy
- Correcting the acidosis (ensure not only O2 but that releasing CO2 as well)
- IV fluids
- Maintain thermoregulation
- Monitor for sxs of sepsis
?
Is a chronic lung disease of infancy
A cause of morbidity and mortality in very low birth weight infants (<1000 g in weight) and infants who have survived RDS
Manifestations include;
- tachycardia
- tachypnea
- increased work of breathing
- retractions
- prolonged exhalation with use of accessory muscles
- pallor
- cyanosis
- activity intolerance
- weight loss
- restlessness and irritability
Bronchopulmonary dysplasia (BPD)
___: supplemental oxygen for at least 28 days, less than 30% oxygen at 36 weeks
___: supplemental oxygen for at least 28 days, no longer required by 36 weeks gestational age
___: supplemental oxygen for at least 28 days, greater than 30% oxygen at 36 weeks
Moderate
Mild
Severe
Many infants improve but as this is a chronic disease, they develop a bronchial asthma
This is why our preterm infants are at a higher risk for developing asthma later in life
?
Bleeding around and into the ventricles of the brain, caused by ruptured blood vessels
Most commonly happens in the first few days of life
This does happen in term infants as well due to asphyxia and trauma
Intraventricular hemorrhage
Causes include;
- blood pressure fluctuations
- asphyxia
- respiratory distress requiring mechanical ventilation (or intubation)
- fluctuating cerebral blood flow
- rapid volume expansion
- hypercarbia (CO2 retention)
- acidosis (due to retaining CO2) and
- hypoglycemia
* Signs may be subtle and few; US around 7 days
* Can cause ___ to occur - ventriculoperitoneal shunt may be required
* Daily head circumference and monitoring for neurological changes
hydrocephalus
Intraventricular Hemorrhage - Grading
___: hemorrhage extends into the lateral ventricles
___: causes distension of the ventricles as blood fills that space
___: very small bleed at the germinal matrix
Grade 2
Grade 3
Grade 1
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Can cause visual impairment or blindness in preterm infants
* Results from injury to retinal blood vessels - though cause of injury is unknown
- Thought to happen from high levels of O2, prolonged ventilation, acidosis, sepsis, shock, intraventricular hemorrhage, hyperglycemia, and fluctuating blood O2 levels
* Should have eye assessment 4 weeks after birth to monitor for changes
* Laser surgery is the current treatment of choice
Retinopathy of Prematurity
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Is a serious inflammatory condition of the intestinal tract that can lead to necrosis of the intestinal mucosa
Most commonly affects ileum and proximal colon
* Mortality rate is 10-30%
* Immaturity of the intestines
- Enteric feedings that are too early or introduced too fast increase risk
- Breastmilk may have a preventative effect
Symptoms include feeding intolerance, increased abdominal girth, increased gastric residuals (not digesting well), decreased bowel sounds, visible loops of bowel, vomiting, abdominal tenderness, blood in the stools
Necrotizing Enterocolitis
Necrotizing Enterocolitis
* Research is undergoing regarding the use of probiotics in prevention of NEC
* Treatment includes antibiotics, discontinuation of oral feedings, gastric suction, IV fluids, and use of parenteral nutrition to rest the intestines
* Surgery is necessary if perforation occurs
* Encourage mothers to provide infants with breastmilk
___ ___ Infants
Infants born after the 42nd week gestation, increasing their risk for multiple complications
May continue to be well supported by the placenta or may experience placental insufficiency
- Risk of postmaturity syndrome or dysmaturity syndrome
> Placental functioning decreases that leads to a decrease in amniotic fluid volume which increases the risk for cord compression
> Inadequate O2 and nutrient exchange to fetus as a result of this and creates hypoxia and malnutrition
- Occurs in 20% of post-term pregnancies
- Polycythemia increases the risk of hyperbilirubinemia and jaundice
Post-Term [Infants]
* Risk of fetal weight surpassing 4000g (8lb 13 oz)
* Higher risk of fetus passing meconium before birth, increasing risk for aspiration
* Can appear thin, have loose skin; little subcutaneous fat stores present; little or no vernix; abundant hair on head; long fingernails; skin is wrinkled, dry, cracked or peeling; meconium-staining of skin
* Assess for hypoglycemia
* Risk for meconium aspiration at birth
* Provide early and frequent feedings (compensate for poor nutrition at birth)
* Are at risk for having polycythemia (due to hypoxia before)
?
Infants who fall below the 10th percentile on size growth charts; also called fetal growth restriction (FGR)
Risk factors include congenital malformations, chromosomal abnormalities, genetic factors, fetal infections, and placental issues
10-20 times higher perinatal morbidity and mortality rate
Low APGAR scores, meconium aspiration, hypoglycemia, polycythemia, and inadequate thermoregulation reported more frequently
Variations: Symmetric Growth Restriction versus Asymmetric Growth Restriction
* Focus is on prevention via good prenatal care; after diagnosis, close monitoring and early delivery if needed
Small for Gestational Age Infants (SGA)
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Occurs when the body is proportionate and appears appropriately developed for its size
Involves the whole body
Caused by congenital anomalies, genetic disorders, exposure to infections in early pregnancy
Could also be a normal genetic predisposition (e.g. a thin and tiny mother that carries a thin and tiny baby)
Symmetric Growth Restriction
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State now caused by a condition that typically begins in the 3rd trimester that’s interfering with that uteroplacental function and nutrition
Fetal head seems large for the rest of the body
Asymmetric Growth Restriction
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Infants who weigh above 90th percentile for gestational age on intrauterine growth charts
* More likely to have a longer labor/labor dystocia (due to an overdistended uterus); obtain injury during labor/birth; and be delivered via C-section
* Shoulder dystocia - higher risk
* Congenital heart defects
* Higher mortality rate
Large for Gestational Age Infants (LGA)
