Lecture 13: High risk neonates

Level 1 care: Well newborn nursery

Care for infants ≥ 35 weeks and stabilize infants < 35 weeks for who are ill for transport to a higher level facility

Level 2 care: Special care nursery

• Care for infants ≥ 32 weeks and ≥ 1500 g

• Transitional care after NICU

• Provide ventilation/CPAP for < 24 hrs

• Stabilize infants who are ill for transport

Level 3: NICU

Provide sustained life support for infants < 32 weeks for <1500 g

• full range of respiratory support, including high-frequency ventilation and inhaled NO

• readily accessible to many specialists

Level 4: Regional NICU

• Located within institution able to perform complex surgical care

• Full range of specialists

• Facilitate transport

Activation of stress response cascade (7 steps)

1. HPA axis activated

2. Cortisol

3. Inflammatory cascade

4. Free radicals

5. Oxidative stress

6. Cellular injury

7. Disease

When is the most important time for brain development?

3rd trimester

Late preterm

34-37 weeks gestation

Moderately preterm

32-34 weeks gestation

Very preterm

28-32 weeks gestation

Extremely preterm

< 28 weeks gestation

Periviable birth

Somewhat viable birth

• 20 0/7 weeks to 25 6/7 weeks

Prematurity primary concerns

• Poor Thermoregulation

• RDS

• Intraventricular hemorrhage

• Patent Ductus Arteriosus

• Necrotizing enterocolitis (NEC)

• Nutrition, growth, and feeding

Preterm babies: Thermoregulation

Thin epithelium + large SA = more loss of heat

• hypothermia increases mortality in preterm infants

How can we prevent hypothermia is preterm babies? (4)

• Hats

• Polyethylene bags (helps with insensible water loss)

• Radiant warmer

• Increase room temp

Preterm babies: Respiratory Distress Syndrome

development of the bronchi and terminal bronchips occurs by 17 weeks, but 17-26 weeks is a critical time for alvioli development

Surfactant

substance that reduces the surface tension of an air/liquid interface within the alveoli in the lung — keeps lungs from collapsing

Intraventricular hemorrhage (IVH)

geminal maxtric is a highly vascularized area of the brain that is prone to bleeding, especially in premies

Grades of IVH (4)

• Grade 1: isolated germinal matrix

• Grade 2: bleeding into ventricle without dilation

• Grade 3: bleeding into ventricle with dilation

• Grade 4: Involves the parenchyma of brain

Periventricular leukomalacia (PVL)

necrosis and softening of white matter near the brain's ventricles, which can contribute to neurodevelopmental delays and other brain complications

• most common in premies

Ductus venosus transitional circulation

1. Birth

2. Umbilical cord clamped

3. SVR rises

4. ductus venosus closes from lack of BF from placenta

1. PVR falls

2. Functional closure of PFO bc left side pressure > right

3. Functional closure of PDA bc removal of prostaglandins (produced by placenta) and increased O2 levels

What is the result of exposure of O2 to the lungs?

• Functional closure of PFO bc left side pressure > right

• Functional closure of PDA bc removal of prostaglandins (produced by placenta) and increased O2 levels

1. PVR falls

2. Functional closure of PFO bc left side pressure > right

3. Functional closure of PDA bc removal of prostaglandins (produced by placenta) and increased O2 levels

Patent ductus arteriosis

congenital heart defect where the ductus arteriosus doesn’t close after birth

Why are infants in respiratory distress (esp. preterm) at risk for PDA not closing?

due to the infant not being able to fully use lungs and intake O2

Necrotizing Enterocolitis

where intestinal tissue becomes inflamed, dies, and can lead to perforations, severe infection, and high mortality rates

• most common in premies

Factors predisposing to NEC

• Genetic

• Characteristics of the immature fetal intestine

  • altered microbiota

  • inadequate intestinal barrier function

  • excessive inflammatory response

NEC signs and symptoms

• Abd distension d/t intestinal pneumatosis and pneumoperitoneum

• Loopy bowel

• Signs of infant lethargy

• Feeding intolerance

• Hematologic: low platelets

• Metabolic: hyponatremia, hyperkalemia, acidemia

NEC etiology (5)

• Hypoxic insult

• Enteral feedings

• Sepsis

• Microbiome

• Inflammatory mediators

NEC prevention (3)

• BM feeding

• Prevent preterm birth

• Infection prevention

NEC treatment

• Bowel resection

• Triple abx

• NPO

• Wall suction to decompress bowel

• Serial xrays to track bowel progression/health

• Slow reintroduction of PO

When does coordination of suck, swallow, and breath develop?

32 weeks gestation

What is the goal of feeding for a premie?

Feeding is can exercise — goal is to expend as little energy as possible

How can we help premies expend as little energy as possible when feeding?

• Cue-based feeding

• Slow flow bottle nipple

• Side-lying position

Late preterm infant

34-37 weeks gestation

When can late preterm infants often be discharged (early side)?

2-5 days after birth

What are late preterm infants are at risk for? (5)

• Poor feeding

• Hyperbilirubinemia (can’t break down RBCs yet)

• Hypoglycemia

• Hypothermia

• Infection

Post-maturity

>42 weeks gestation

Post-maturity risks

• Uteroplacental insufficiency

• Meconium aspiration

Post-maturity placental insufficiency

this occurs because placental is really only supposed to last 40 weeks

• causes hypoxia before and/or during labor, leading to:

  • poor resp. effort after birth

  • hypoglycemia

  • mec aspiration

  • hypoxic ischemic encephalopathy

Post-maturity meconium aspiration

with perinatal stress or post-maturity, there is often the passage of meconium before/during/immediatley after delivery and can be aspirated into lungs

• This is our biggest concern with post-mature babies bc it can cause respiratory distress!

Pulmonary HTN

BVs of baby’s lungs don’t open, leading to a hypertensive state in pulmonary vasculature — too much blood bypasses the lungs so O2 can’t get into blood, leading to a low O2 state for brain and body

• most common cause is meconium aspiration

Small for gestational age (SGA)

defined as weight <10th percentile for weeks of gestation

Symmetric SGA

both head circumference and weight are below threshold

Asymmetric SGA

weight below threshold, but head circumference WNL

• better outcomes bc brain is fully developed

What may SGA indicate?

• Poor placental function

• Inherent abnormality of fetus (e.g., genetic disorders)

What are SGA infants at risk for?

• Asphyxia

• Cold stress

• Hypoglycemia

• Polycythemia

What are SGA infant at risk for long-term?

poor neurodevelopmental outcomes

Large for Gestational Age (LGA)

>90rh percentile for gestational age

Risk factors for LGA

• Diabetic mothers

• Large parents

What are LGA infants at increased risk for? (3)

• Birth trauma

• Asphyxia

• Hypoglycemia

Neonatal hypoglycemia treatment (3)

• Feeding

• Glucose gel

• IV glucose

Most common type of birth injury

clavicular fracture

• bc of shoulder dystocia

Types of birth trauma: skeletal injuries (4)

• Skull

• Clavicular

• Humerus

• Femur

Types of birth trauma: peripheral NS injuries (2)

• Brachial plexus injuries

• Facial palsies

Types of birth trauma: CNS (4)

• Intracranial hemorrhage

• Hypoxic ischemic encephalopathy

• Spinal cord injuries

Cephalohematoma vs Caput Succedaneum

• Cephalohematoma: collection of blood below the periosteum and does not cross the periosteum

  • dewveops over 24 hrs

• Caput: collection of blood above periosteum and crosses suture lines

  • present at birth

What types of vaccines can be given during pregnancy?

only inactivated vaccines

TORCH infections

group of infectious diseases transmitted from a pregnant person to a fetus or newborn, causing severe congenital anomalies, stillbirth, or developmental issues

• Toxoplasmosis

• Other (syphilis)

• Rubella

• Cytomegalovirus

• Herpes

If mom is Group B Strep (GBS) positive, how long after contraction will the baby show the illness?

1 week

GBS s/s in mother

• Fever

• GBS bacteruria

• Preterm delivery

• Prolonged ROM (>18 hrs)

GBC s/s in infants (7)

• Lethargy

• Poor feeding

• Resp difficulties

• Tachypnea

• Grunting

• Hypoxia

• Possible fever

GBS late onset in an infant

7-89 days of life and typically presents with meningitis

• needs a sepsis work-up

Toxoplasmosis transmission (2)

• Undercooked or raw meat/shellfish

• Cat feces

Congenital toxoplasmosis fetal complications

• Visual and hearing impairment

• Learning disabilities

• Intellectual disabilities

Syphilis transmission

skin and mucocutaneous exposure

Syphilis fetal complications

• Still birth

• Hydrops fetalis

• Preterm birth

Syphilis complications at birth up to 8 weeks after birth

• Hepatosplenomegaly

• Mucocutaneoius lesions

• Pneumonia

• Osteochondritis

• Hemolytic anemia

• Thrombocytopenia

Late infant manifestations of syphilis (2)

• Vision impairment

• Abnormalities in bone, joints, teeth, and skin

Syphilis treatment

penicillin

Rubella transmission

transmitted through direct or droplet contamination from nasopharyngeal secretions

Congenital Rubella syndrome may result in… (4)

• Fetal death

• Congenital anomolies with eyes or heart

• Hearing loss

• Neurological abnormalities

Rubella vaccine and pregnancy

Rubella vaccine is a LIVE vaccine, so it CANNOT be given during pregnancy

• must be given before or immediately after delivery

Cytomegalovirus (CMV) transmission

• Transplacental (most concerning)

• During birth (contact with secretions)

• Postnatally via breast milk or saliva/urine

• *Women at highest risk for transmission are those exposed to saliva or urine of young children

CMV infant risks

• Hearing loss

• Vision loss

• Intellectual disability

• Microcephaly

• Seizures

Herpes Simplex Virus (HSV) neonatal consequences

• Presents with:

  • cutaneous lesions

  • Opthalamic involvement

  • Neurological involvement

• High mortality with infection

HSV transmission prevention

avoidance of vag delivery with an active infection

How can HIV be transmitted from mother to infant?

During pregnancy, intrapartum (labor/delivery), and postpartum (breastfeeding)

How does HIV transmission occur during pregnancy?

Transplacental (hematogenous) or ascending infection from genital tract to amniotic fluid/membranes

How does intrapartum HIV transmission occur?

Mucocutaneous contact with maternal blood, amniotic fluid, or genital secretions

What medication reduces transmission during labor in high viral load?

IV Zidovudine intrapartum

What is given to the infant after being born to a mother with HIV?

Antiretroviral prophylaxis for 4–6 weeks

Neonatal Abstinence Syndrome (NAS)

is withdrawal in a newborn after in-utero exposure to opioids

When is NAS present?

2-3 days after birth

NAS s/s (3)

• Tremors

• Hypertonic

• Inability to eat, sleep, or be consoled

NAs treatment

Weaned off over days to weeks of these drugs:

• Methadone

• Morphine

• Nuprenorphine

• Clonidine

Fetal Alcohol Syndrome

caused by alcohol exposure during pregnancy, leading to permanent physical, neurologic, and developmental abnormalities

• dose-dependent

Hemolytic Disorders: Rh/ABO incombatability (mom Rh- and baby Rh+)

Fetal RBCs are destroyed by maternal antibpodies

• anemia and hydrops (extreme edema)

• Erythroblastosis fetalis (hemolytic disease of newborn)

Rhogam

prevents mom from developing anti-Rh antibodies

• needs to be given anytime risk for maternal-fetal transfusion

Hyperbilirubinemia

elevated bilirubin level in the blood leading to jaundice in newborns

Hyperbilirubinemia causes

• Anything that increases rate of RBC breakdown (infection, prematurity, caput, cephalohematoma)

• Liver dysfunction

• Hypoalbuminemia

• Poor GI function

• G6PD deficiency — causes hemolytic anemia

Kernicterus

a severe, permanent brain injury caused by very high levels of unconjugated bilirubin crossing the blood–brain barrier in a newborn

• preventable and considered a “never event”

Vetricular septal defect (VSD)

Is blood flow to lungs increased or decreased in VSD?

decreased bc bypassing defect in ventricle

• O2 stats will be lower

Coartation of the Aorta

If a baby has a severe coarctation, they will be…

very blue

Tetralogy of Fallot

4 defects:

• Large VSD

• Overriding aorta that straddles VSD

• Pulmonary stenosis

• RV hypertrophy

Tet spell and treatment

Acute cynaotic event that can be semi-treated by bringing knees ti chest to increased systemic vascular resistance

Transposition of the Great Arteries

Aorta and pulmonary arteries are switched

Cleft lip and palate risk factors

• Alc

• Smoking

• Diabetes

• Epilepsy meds

Primary concern of cleft lip/palate

feeding bc baby cannot create a seal

• nasopharyngeal reflux (milk will come out of nose)

Cleft lip/palate special bottle

long nipple to get past cleft palate