HIGH RISK NEWBORN CLASS 2

CLASS # 11
Linares
9/22/17
➤ Any baby born with a higher
than normal chance of morbidity
➤ Viability is at 23 weeks
gestation. Still a lot of issues,
difficult to sustain life
TERMINOLOGY
➤ According to size (chart in Wong, 338)
➤ AGA: weight falls b/t 10th and 90th
percentiles on intrauterine growth
curves
➤ IUGR: intrauterine growth restriction
➤ SGA: weight falls below 10th
percentile
➤ LGA: weight falls above 90th
percentile
➤ According to gestational age:
➤ Premature: born before completion of
37 weeks. Highest rate of mortality in
first 72 hours
➤ Full term: born b/w 38-42 weeks
➤ Postmature: born after 42 weeks
NICU UNITS
➤ Some hospitals have no capacity
to care for premature babies and
have to send them to other
facilities. Try to ship inutero
➤ Level 1: 35 weeks and over that
isn’t high risk. Generally send
high risk to other facilities
➤ Level 2: moderately ill infants 32
weeks or more. Can do short
term ventilator support,
medications, stabilization
➤ Level 3: highest skilled in NICU
care. Extremely preterm babies.
Have ECMO and surgeons on
hand
NEONATAL MEDICINE ADVANCEMENTS

➤ New ventilation: high

frequency ventilator
(oscillation): give many small
breaths that don’t hyperinflate
the lungs and cause damage.
Good for long term ventilation
➤ Ways to tell what is occurring
inutero
BALLARD SCALE
➤ Gives accurate picture of gestational age
of baby
➤ Needed to determine viability of baby
➤ What characteristics make baby more
preterm: scrawny, poor muscle tone,
extended attitude, less subcutaneous
tissue, lanugo, ear cartilage not stiff,
before 26 weeks eyelids may still be fused,
skull bones still soft, minimal creases on
soles and palms, female majora not
formed yet, translucent skin, vernix
caseosa, breast tissue not developed, male
scrotum has no rugae (Wong, 366)
➤ Post term: no vernix, lots of head hair,
long fingernails, dry cracking skin, may
have wasting, meconium stain, creases
over whole feet and palms
PRETERM NEWBORN
➤ Body system immaturity affecting transition
to extrauterine life; increasing risk for
complications
➤ Size does not determine whether they are
newborn or not, or the amount of care they
require. Must rely on assessment and
symptoms
➤ Risk factors: maternal age (young or
advanced), socioeconomic status, education
of mother, preconception weight of mother,
substance abuse, smoking, 2nd pregnancy in
12 months, pre-existing medical
conditions(HTN, etc.)
➤ Have difficult time transitioning because of
their issues and immature systems
➤ Respiratory: smaller airways at risk for
obstruction and have a hard time clearing
fluid, immature resp control centers in the
brain = apnea, oxygenation issues
THERMOREGULATION
➤ No subcutaneous tissue, vessels closer to
surface
➤ Not flexed
➤ Encouraging thermoregulation
(interventions): make sure no draft,
radiant warmer, skin to skin, swaddling,
air currents (don’t place by window),
warm your stethoscope and hands, warm
IV fluids and oxygen, monitor temp, look
for signs of cold stress (hypoglycemia, resp
distress)
➤ Can lead to resp issues, increased resp rate
which can make them hypoxic. Have more
acid circulating in body = resp acidosis
➤ This can exacerbate other disorders
(hyperbilirubemia)
PREVENT INFECTION
➤ Hand washing, educate parents and
visitors. Sterile gloves, sterile water.
No artificial nails or nail polish
➤ Immature immunity = increased risk
➤ Umbilical cord , circumcision,
invasive lines, multiple stick sites are
pathways for infection
➤ Very thin skin: can come off (tape
can pull it off. No tape or adhesives),
don’t remove vernix because
scrubbing, pad pressure areas, place
them therapeutically, turn them,
pressure mattresses, barrier
ointment especially with meconium
 NUTRITION AND FEEDINGS
➤ 85 ml per kg = blood vol. what if you’re drawing blood regularly and
they're urinating and they aren’t eating so……
➤ What to do: measure I/O include blood draws and medication
administration (be careful with amounts in dosages. Concentration of
med vs. dose measurement. Adult dose vs. baby dose. DO MATH, READ
BOTTLE), weigh diapers (1g of weight = 1ml. Have to weigh dry diaper
and then weigh wet diaper and subtract weight of dry diaper to get exact
weight of fluid), daily weights sometimes more often.
➤ Weight is very good indicator of fluid status
➤ Can have resp issues, edema, perfusion issues if over or under hydrated
➤ Watch IV site for infiltration
➤ Buritrols on IVs
➤ Kidneys and liver are immature, can’t metabolize medicine normally
➤ Don’t feed if risk for aspiration, and don’t know how mature their gut is
➤ Breast milk is best (VITAL for preterm babies, their milk is specifically
tailored for THAT preterm baby), have mother pump breast milk and
save it for when baby is ready. Educate mother. Hospitals use donor milk
if mother can’t breastfeed
➤ Suck/swallow reflex hasn’t developed, assess for ability
➤ Poor muscle tone so may not be able to latch
➤ Small amounts and watch how they digest
➤ Parenteral nutrition (NG). Whatever residual you get will be part of their
feeding, if a lot of residual inform doctor
➤ Do non nutritive sucking during feedings so they will learn that sucking
= food
➤ Gravity feed
NUTRITION AND FEEDINGS
➤ Wong, 348, cues to stop feeding,
stress cues (bradycardia, apnea,
aspiration. Stop feeding and call
doctor)
➤ Feedings shouldn’t take longer than
20-25 minutes b/c they are using
energy. If taking longer, may need to
go back to other form of feeding (NG)
➤ Assess bowel sounds and stools
(should be consistent, not hard)
➤ Should have energy to feed and not
tire out
➤ Feeding techniques (Wong, 349) (no
pumping b/c aspiration)
➤ If formula = add calories, but breast
milk always best
THERAPEUTIC HANDLING OF HIGH RISK NEWBORNS

➤ Pain (ASSESS for it)

➤ Oral glucose can help
➤ Can administer analgesics
➤ Skin to skin helps with several
issues and helps stabilize baby’s
systems and behaviors, gentle
touch
➤ Co-bedding
➤ Change position, decrease
pressure
➤ Cluster care to decrease energy
waste, glucose consumption, resp
distress
PARENT-INFANT BONDING
➤ Foster attachment with parents
➤ Skin to skin (even father)
➤ Allow parents to ask questions
➤ Red flags (Old’s, ): don’t name baby/
visit/touch/have questions
➤ Still want them to bond even if death
is certain because helps with grieving
(baptism, footprints)
➤ Allow them to bring items, and
perform any care they can
➤ Provide welcoming, private
environment
➤ Siblings can visit, want them to teach
too
➤ Estimated discharge = around due
date
PARENT INFANT BONDING
➤ Getting ready to go home:
teach CPR, car seat test,
educate parents on feeding
and care
 APNEA
➤ 20 seconds or more without breathing
➤ Apnea prematurity = most premature
babies have apnea. Apnea contributes to
prolonged hospital stays
➤ Usually resolves at about 37 weeks
➤ Have alarms for apnea that alert staff. First
check patient to assure whether or not there
is actually an issue
➤ If full term baby has apnea, it’s related to
someone else (Wong, 358)
➤ If baby is apnic - do tactile stimulation, if
they don’t come out of it bag them, if still
dusky give oxygen to increase oxygen
saturation
➤ Prevent apnea- caffeine citrate IV low dose
to stimulate (watch for signs of toxicity),
CPAP, if severe may be on ventilation,
maintain airway
TRANSIENT TACHYPNEA
➤ Lasts for about 72 hours
➤ Amniotic fluid in the lungs that isn’t
clearing
➤ Tachypnea, nasal flaring, grunting, low
O2 sat, crackles….etc.
➤ Should clear/resolve over 72 hours,
usually has no long term effects
➤ Cause: c-sec, mother on drug that
causes resp depression
➤ Interventions: oxy hood, no masks long
term, keep oxygenated, can’t feed them
may have IV, position them, stimulation
➤ Resp distress syndrome mimics this,
but it doesn’t resolve in the 72 hour
time frame
 RESP DISTRESS SYNDROME
➤ Prone positioning is effective: increases O2, tidal volume,
helps expand chest, oxygenate better when prone
➤ Teach parents that they CANNOT DO THIS at home and
why
➤ A week before they go home change them to supine
➤ What is RDS: Surfactant deficiency, primarily a disease of
immaturity, can occur in other disorders (gestational
diabetes, c-section, cold stress, MALE
GENDER(specifically white) increases risk
➤ Cycle of RDS: alveoli collapse because of lack of
surfactant, starts with nasal flaring/grunting, then
contraction and tachypnea, then cyanosis. Leads to
atelectasis, low O2, high CO2, resp acidocis
➤ Chest X-ray: granular pattern (ground glass)
➤ Interventions: treat sx, oxy hood, CPAP, intubation,
varying degrees of ventilation, keep saturation at 95%,
prevent vasoconstriction, endotrachial tube to administer
meds to increase surfactant(synthetic surfactant put in
lungs) after admin may see some decrease in O2 sat but
then improves
➤ Prevention: give mother steroids before birth of
premature baby, prevent preterm delivery, insulin
antagonizes surfactant so may cause resp distress even in
post term baby
RESP DISTRESS SYNDROME
➤ If they don’t improve from tx:
ventilator/oscillator, blend
oxygen with nitric oxide
(causes smooth muscle
relaxation and reduces
vasoconstriction), umbilical
catheter, morphine, ECMO if
nothing else works, IV fluids
➤ Interventions: communicate
with parents, prone position
MECONIUM ASPIRATION
➤ In full/post term infants
➤ Fetus has passed meconium
inutero
➤ Sx: same as RDS except will
have meconium, may have tint
to skin because of meconium
➤ If no resp effort, LET
DOCTOR SUCTION
MECONIUM
➤ Meconium is tenacious and
can destroy surfactant
BRONCHOPULMONARY DYSPLASIA AND CHRONIC LUNG
DISEASE

➤ Due to long term ventilation

➤ BPD
➤ CLD
➤ Sx: issues with G and D,
mimic asthma as they grow
➤ Tx: by sx and severity
➤ Long term issues:
➤ Prevention: low settings on
ventilators, high frequency
ventilation
NEONATAL SEPSIS
➤ Can lead to resp distress
➤ Can happen to premature or post term
➤ Group B strep contributes
➤ Sx: vague and subtle/nonspecific, hypothermia/
temp instability, don’t want to eat, lethargic,
irritable, apnea, bradycardia, pallor(color changes)
(Wong, 385)
➤ Diagnostic: blood culture, broad spectrum AB
until culture comes back, x ray(look for signs of
resp distress), c reactive protein(elevated),
CBC(white count can be up to 30,000 and be
normal, so not great indicator of infection. So
CBC differential necessary. Look for bands
(immature neutrophils) and these indicate a high
probability of infection), eosinophils are increased
➤ Tx: treat sx, broad spectrum AB until cultures
come back (IV AB), keep them hydrated,
(however AB can kill good bacteria too, like
bacteria in gut. Puts them at increased risk for
bleeding), breastfeeding helps establish things for
immunity
NECROTIZING ENTEROCOLITIS (NEC)
➤ Mostly in premature babies
➤ Basically infection in gut
➤ Can cause perforation, necrosis
➤ If suspected, transported to higher skilled NICU
➤ During an illness in a high risk baby, the gut is not
to priority so there may be decreased perfusion and
may cause ischemia and decrease in bacteria in it
➤ Tx: formula helps bacteria grow(but can also
colonize bad bacteria), to prevent = breastfeeding,
➤ Sx: inflammation, edema, increased abd girth/
distention, blood in stools, gastric residual increases,
feedings sit in the stomach, x ray (sausage shaped
dilation of intestines/soap suds), lethargy, poor
feeding, apnea, feeding intolerance(emesis)
➤ Interventions: assess for sx, NO RECTAL TEMP
➤ Prevention: steroids, NPO, breastfeeding, call doctor,
stop all oral feedings, NG tube to decompress abd,
AB, parenteral nutrition, watch for perforation
➤ After AB for 7-10 days and looks better = reestablish
feedings
RETINOPATHY OF PREMATURITY ROP

➤ The more premature, the

worse it can be
➤ Prevention: do not need 100%
oxygenation because increases
collateral circulation
INTRAVENTRICULAR HEMORRHAGE (IVH)

➤ In premature babies
➤ Vessels can rupture and bleed into the
ventricles
➤ Can be silent or very severe, long term,
cognitive impairment, mobility
impairment
➤ Prevention: prevent increases in
intracranial pressure(position with head
midline and elevated 30 degrees, no
crying, no rapid IV fluids, daily head
circumference measurements), maternal
steroids, magnesium sulfate to mother
during labor
➤ Sx: odd eye movements, any subtle
changes in assessments
➤ Tx: not many things to be done, depends
on how severe it is