Care of the High-Risk Neonate

level 1

well newborn nursery for infants >35 weeks and stabilize infants <35 weeks or who are ill for transport to higher lvl facility; pp/mother-baby

level 2

special care nursery for infants >32 weeks and >1500g; transitional care after NICU; provide ventilation/CPC for <24h, stabilize infants <32 weeks or who are ill for transport

level 3

NICU; provide sustained life support for infants <32 weeks or <1500g; all ages; full range of respiratory support, including high-frequency ventilation and inhaled NO

• high risk newborn-cardiac procedures

level 4

located within institution able to perform complex surgical care; cardiac-echmo

NIDCAP

reduces stimulation, pain, and isolation; improves brain development, health, and quality of life of infants

pathophysiologic processes in high risk neonates

prematurity/post-maturity, abnormal growth (small/large for gestational age), birth trauma, infectious diseases, neonatal abstinence syndrome/fetal alc syndrome, hemolytic disorders=hyperbilirubinemia, congenital anomalies

prematurity

before 37 weeks

periviable birth

20 0/7 weeks-25 6/7 weeks

causes of PTL

severe preeclampsia, multiple gestation, infectious diseases, hx of PTL

causes of death in PTL

congenital anomalies, CNS injuries, bronchopulmonary dysplasia, NEC, resp distress syndrome, immaturity

primary concerns for prematurity

poor thermoregulation, RDS, intraventricular hemorrhage, patent ductus arteriosis, NEC, nutrition/growth/feeding

thermoregulation

• hyperthermia increases mortality and morbidity in preterm infants

• thin epithelium

• relatively large surface area

• prevention: hats, polyethylene bag, radiant warmer, increase rooom temp

RDS

development of the bronchi and terminal bronchioles occurs by 17 weeks, but the period from 17-26 weeks is a critical time for development of the alveoli

surfactant

substance that reduces the surface tension of a air/liquid interface within the alveoli of the lung→keeps alveoli from collapsing

CPAP

helps maintain alveoli open

intraventricular hemorrhage

germinal matrix is highly vascularized area of the brain that is prone to bleeding

IVH increased risk of bleeding with

rapid volume expansion, HTN, hypoxic-ischemic insult, acid-base imbalance

grade 1 IVH

isolated to germinal matrix

grade 2 IVH

bleeding into ventricle without dilatioon

grade 3 IVH

bleeding into ventricle with dilation

grade 4 IVH

involves the parenchyma of brain

Periventricular leukomalacia

bleeding around the ventricles such that we have white matter in the brain

Necrotizing enterocolitis (NEC)

disease of preterm bowel=inflammation and necrosis of the bowel; most common cause of GI-related morbidity/mortality in NICU

Necrotizing enterocolitis (NEC) infants at risk

preterm, asphyxia, formula feeding

NEC pathogenesis

mucosal injury, loss of integrity/bacterial proliferation, invasion of mucosa, intramural gas (pneumotosis), transmural necrosis, perforation, sepsis, peritonitis

NEC predisposing factors

genetic factors, characteristics of the immature fetal intestine (altered microbiota, inadequate intestinal barrier function, and an excessive inflammatory response)

NEC final pathway

severe necrosis of the small intestine

NEC clinical manifestations

abd distention, loopy bowel, infant lethargy, feeding intolerence, hemaologic: low plts, metabolic: hyponatremia, hyperkalemia, acidemia

NEC diagnosis

intestinal pneumatosis, portal venous air, pneumopertoneum

NEC intestines

inflammation and ischemia, coagulation necrosis, intramural air, bowel perforation

NEC prevention

human milk, attempt to prevent preterm, prevent infection

NEC tx

triple abx, bowel rest, serial x ray, bowel resection, careful with feeding

immature GI tract

parenteral nutrition; start and increase enteral feedings slowly (human milk); NG tube

around 32 weeks

coordination of sucking, swallowing, and breathing

feedings goal

little energy expended as possible; cue-based, slow flow, side-lying

Preterm Infant

34-37 weeks post-menstrual age; may be cared for in the well-baby nursery; may be discharged with mom 2-5 days after birth

Preterm infant at risk for

poor feeding, hyperbilirubinemia, hypoglycemia/hypothermia, infection

Post maturity

>42 weeks gestation

post maturity risks

uteroplacental insufficiency; mec aspiration

uteroplacental insufficiency

causes hypoxia before and/or during labor, leads to

• poor resp effort after birth, hypoglycemia, mec aspiration, hypoxic ischemic

mec aspiration management

can cause resp distress→neonatal team for delivery of MEC infants and prepare for endotracheal intubation

infant with good resp effort

normal post-delivery care

poor muscle tone and/or inadequate breathing

normal resuscitation, suction if mec is obstructing the airway

Pulmonary HTN

blood vessels to babies lungs don’t open→ECMO

ECMO

blood bypasses lungs

SGA

defined as weight <10th percentile for weeks of gestation

symmetric SGA

both head and weigh are below threshold

asymmetric SGA

weight below threshold, but head circumference WNL

SGA risks

asphyxia, cold stress, hypoglycemia, polycthemia

SGA long term

at risk for poor neurodevelopmental outcomes

LGA

over 90th percentile for gestational age

LGA risk factors

infants of diabetic mothers, large parents

LGA increased risk for

birth trauma, asphyxia, hypoglycemia

neonatal hypoglycemia

• preventable cause of neurologic injury and NDI

• more common in LGA babies, particularly gDM

Neonatal hypoglycemia tx

feeding, glucose gel, IV glucose

birth trauma types

skeletal: skull, clavicle, humerus, femur

PNS: brachial plexus injuries, facial palsies

CNS: intracranial hemorrhage, hypoxic ischemic encephalopathy spinal cords injuries

cephalohematoma

collection of blood below the periosteum; does not cross suture line; envolves over 24 hrs

caput succedaneum

collection of blood above periosteum; crosse suture line; present at birth

maternal immunizations to benefit infant (good to give during pregnancy)

only give inactivated; influenza, tetanus, and pertussis

GBS

maternal fever, GBS bacteruria, preterm delivery, prolonged ROM (>18 hrs)

GBS fetal complicatioons

lethargy, irritability, poor feeding, resp difficulties, + fever, tachypnea, grunting, hypoxia

GBS tx

abx during perinatal period; at least 4 hrs before baby born

GBS early onset

develops in first week of life

GBS late onset

illness develops between 7-80

TORCH

toxoplasmosis, other (syphilis), rubella, cytomegalovirus, HSV

toxoplasmosis gondii

• After birth, symptomatic in immunocompetent people 

• Transmitted through undercooked or raw meat/shellfish, cat/feline feces 

• Congenital toxoplasmosis associated with visual (chorioretinitis) and hearing impairment, learning disabilities, and intellectual disabilities (cerebral calcifications and hydrocephalus)

• Highest risk in those with primary infection during pregnancy or in 3 months prior to pregnancy 

• Prevention is key; antimicrobial therapy available

syphilis

• STI transmitted through skin and mucocutaneous exposure (incubation period 10-90 days) 

• Congenital syphilis can present with stillbirth, hydrops fetalis, or preterm birth 

  • At birth or 8 weeks= hepatosplenomegaly, mucocutaneous lesions, pneumonia, osteochondritis, hemolytic anemia, or thrombocytopenia

  • Late manifestations include hearing and impairment, abnormalities in bone and joints, teeth, and skin 

• Screening, identification, and treatment (penicillin)= HIGHLY PREVENTABLE

rubella

• Transmitted through direct or droplet contamination from nasopharyngeal secretions 

• Congenital Rubella Syndrome 

  • Fetal death, constellation of congenital anomalies involving eyes (cataracts, microphthalmos, glaucoma), heart, sensorineural hearing loss, neurologic abnormalities (behavioral disorders, intellectual disabilities, autism) 

  • SGA, pneumonia, radiolucent bone disease, hepatosplenomegaly, thrombocytopenia, “blueberry muffin”, rash 

• Live Vaccine. Vaccinate PRIOR to pregnancy. Prenatal …

CMV

• Herpes-family virus; shed in saliva, urine & semen

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

• Risk for sequelae more common in primary infections during pregnancy: Hearing loss, vision loss, intellectual disability, microcephaly, seizures

• Present with jaundice petechiae 

HIV

• Transmission from pregnant mother to infant can occur 

  • During pregnancy- direct hematogenous, transplacenta, or ascending infection from genital tract to amniotic fluid & membranes 

  • Intrapartum- mucocutaneous contact between fetus and maternal blood, amniotic fluid, and genital tract secretion 

  • PP via breastfeeding- discouraged if safe alternative available 

• Screening! 

• Tx aimed at preventing transmission to infant 

  • If adequate tx and low viral load= scheduled x/s has not been shown to reduce transmission 

  • With high viral load= after labor onset or ROM, C/S has not been shown to reduce transmission

    • IV Zidovudine intrapartum shown to reduce transmission in cases of high viral load 

  • Chemoprophylaxis in infant 4-6 weeks; need 2 neg tests at >6 months 

• Tx for baby= prevent transmission

Neonatal abstinence syndrome

results from in utero opioid exposure; presents 2-3 days after birth

NAS symptoms

tremors, hypertonic, inability to eat, sleep, or be consoled

NAS tx

methadone, morphine, buprenorphine, clonidine weaned off over days to weeks; swaddle, SSC, reduction of noise

NAS assessment

ESC (eat, sleep, console)

Fetal alc syndrome

established evidenced of high levels of alcohol ingestion result in fetal alc syndrome; most comon cause of intellectual disability; epigenetic rls

hemolytic disorders

Rh/ABO incompatibility

hyperbilirubinemia

increases the rate or breakdown of RBCs (infection, prematuroty, caput or cephalohematoma), liver dyfunction, hypoalbuniemia, poor GI function, G6PD

hyperbilirubinemia tx

phototherapy-breaks down hem in RBCs

bilirubin encephalopathy/kernicterus

• preventable form of brain damage caused by excessive levels of bilirubin

• jaundice in first 24 hrs, excessive for infant’s age, rises rapidly (>5mg/dL in 24 hrs)

• measure total serum bilirubin and conjugated bilirubin, blood type and COOMBS, G6PD

• Second line therapy: exchange transfusion

congenital anomalies

coarctation of the aorta, tetralogy of fallot

tetralogy of fallot

• Most common cyanotic defect 

• 4 associated defects: Large VSD, overriding Ao that straddles VSD, RV hypertrophy 

• Degree of cyanosis depends on the degree of pulmonary stenosis 

• “Tet spell”- acute cyanotic spell

• Intervention: put baby in knee-chest position to increase systemic vascular resistance 

spinal cord malformations

spinal cord fuses first in the middle and closes towards the caudal (head) and rostral (tail); malformations occur at two ends= cranium bifidum, spina bidifa, occulta, meningocele, or myelominocele

spinal cord nutritional interventions

folic acid

cleft lip/palate

common birth defect

tx: surgery

nursing care: feeding (create a seal for bottle; nasopharyngeal reflux); seal with finger if cleft lip; special bottle: Medela SpecialNeeds Feeder

Abd wall defects

• The intestines grow rapidly and herniate into umbilical cord (6th-10th week); by 11th week back in abd cavity 

• Body wall then fuses at the umbilical ring to keep intestines in 

• Omphalacele- herniation of abd contents into the umbilical cord (protected); failure of body wall to fuse 

• Immediate intubation & nasogastric tube to suction→don’t want air to get into the intestines

Gastroschisis

• Abd wall defect where viscera protrude into the amniotic cavity (not protected by the umbilical cord) due to incomplete closure of the lateral folds of the abd cavity 

• Occurs to the right of the umbilical cord 

• Immediate intubation, nasogastric tube to suction 

• Cover intestines in sterile saline soaked gauze to keep moist 

• Immediately to OR to reduce: often need silo…

Congenital diaphragmatic hernia

• Incomplete development of the diaphragm→allows intestines to move into thoracic cavity 

• Lung hypoplasia→cause of death in infants with CDH

• Ultrasound 

• Present with scaphoid abd and severe resp distress, abd sounds heard in chest cavity, seen on CXR

congential diagphragmatic hernia tx

EXIT procedures, Ex-utero, intrapartum, tx (requires intense coordination bewteen the neonatal and obstretric surgical teams)

ambiguous genitalia

external genitalia of developing male and female embryos look similar until about 7-8 weeks gestation and do not fully differentiate until 12 weeks ; presence of testosterone, the external genitalia develop into phenotypic female genitalia, requires karyotype testing of chromosome

developmental dysplasia of the hip risks factors

first pregnancy, breech position, female, family hx, swaddling

supporting parents of hospitalized infants (NICU nurse)

practice and promote family-centered care (i.e. include family in rounds, d/c readiness), parental education about baby care is critical (i.e. include family in care where possible), Support parental bonding/getting to know their baby while in the NICU, assess for stress, anxiety, and depression using valid and reliable tools

Myles PSS

parental stress scale-NICU; stress associated with NICU environment, stress associated with baby appearance, disease, and health outcome, stress associated with maternal/parental role

Trauma informed care

• autonomic nervous system responds to stress to restore homeostasis

• activation of stress response (HPA axis)→cortisol→inflammatory cascade→free radicals→oxidative stress→cellular injury→disease

• stressors d/t pain, maternal separation/isolation, sleep interruption/deprivation

• environmental stressors-cold, light, noise

• nutritional stressors

• facilitate parent-child contact + positive stimulation: SSC (kangaroo care), non-nutritive sucking, facilitated tucking/nesting

in NICU we should perform what type of care

clustered care, reduce interruptions to sleep, reduce noise, light, cold, and optimize nutrition

flight or flight

increased HR, RR, diversion of blood from GI tract