The High-Risk Newborn: Problems Related to Gestational Age & Development

Question 1

Approximately 9% of all newborns are sick enough at birth to require special or intensive care

Question 2

Preterm Infants

• Preterm, or premature

! Review safety alert boxes in textbook

Answer 2

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

Question 3

Answer 3

Question 4

Answer 4

Question 5

Answer 5

Question 6

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

Answer 6

* 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

Question 7

Pain

* Greater risk of ineffective pain management

* Interventions include:

• Comfort measures
• Containment or swaddling
• Pacifier
• Sucrose
• Breastfeeding
• Kangaroo care
• Analgesic medication if needed

Question 8

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

Answer 8

surfactant

atelectasis

Question 9

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

Answer 9

CPAP

Question 10

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

Question 11

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]

Answer 11

* Fragile skin = increased risk of broken barrier for infectious pathogen

* Preterm infants have more invasive procedures than the term infant

Question 12

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

Question 13

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)

Answer 13

* 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

Question 14

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

Answer 14

* SPEND TIME WITH THE PARENTS

* Begin preparation for discharge early

Question 15

___ ___ 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

Answer 15

Late Preterm

Question 16

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

Answer 16

* 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)

Question 17

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

Answer 17

* 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

Question 18

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

Answer 18

• 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

Question 19

Common Complications of Prematurity

?

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

Answer 19

Respiratory Distress Syndrome

prematurity

Question 20

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

Answer 20

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

Question 21

?

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

Answer 21

Bronchopulmonary dysplasia (BPD)

Question 22

___: 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

Answer 22

Moderate

Mild

Severe

Question 23

Many infants improve but as this is a chronic disease, they develop a bronchial asthma

Answer 23

This is why our preterm infants are at a higher risk for developing asthma later in life

Question 24

?

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

Answer 24

Intraventricular hemorrhage

Question 25

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

Answer 25

hydrocephalus

Question 26

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

Answer 26

Grade 2

Grade 3

Grade 1

Question 27

?

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

Answer 27

Retinopathy of Prematurity

Question 28

?

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

Answer 28

Necrotizing Enterocolitis

Question 29

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

Question 30

___ ___ 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

Answer 30

Post-Term [Infants]

Question 31

* 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

Answer 31

* 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)

Question 32

?

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

Answer 32

Small for Gestational Age Infants (SGA)

Question 33

?

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)

Answer 33

Symmetric Growth Restriction

Question 34

?

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

Answer 34

Asymmetric Growth Restriction

Question 35

?

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

Answer 35

Large for Gestational Age Infants (LGA)