High-Risk Newborns: Classification and Nursing Care

High-Risk Newborn

Infants who are born considerably before term and survive are particularly susceptible to the development of sequelae related to preterm birth.

An accurate assessment of gestational age is critical in helping the nurse to identify the potential health issues that the newborn is likely to experience.

Late preterm infant

Infants born between 34 and 36 6/7 weeks of gestation.

Often experience morbidities similar to those of preterm infants, including respiratory distress, hypoglycemia requiring treatment, temperature instability, poor feeding, jaundice, and discharge delays as a result of illness

associated with speech, behavioural, and cognitive challenges at follow-up in children 6 years of age

Term infant

Infants born between 37 & 42 completed weeks of gestation.

Post-term/Postmature infant

Infants born at > 42 completed weeks of gestation.

Live birth

Birth in which the newborn manifests any heartbeat, breathes, or displays voluntary movement, regardless of gestational age.

Fetal death

Death of the fetus, at any gestational age, before birth, with absence of any signs of life after birth.

Neonatal death

Death of a newborn less than 28 days of life; early neonatal death occurs in the first week of life; late neonatal death occurs at 7 to 28 days.

The Preterm Infant

Born before completion of 37 weeks of gestation.

At increased risk for health issues because their organ systems are immature and they lack adequate physiological reserves to function in the extrauterine environment.

Issues Affecting the respiratory system of the preterm infant

•Decreased number of functional alveoli

• Deficient surfactant levels

• Smaller airway lumen

• Decreased tracheal cartilage

• Obstruction of respiratory passages

• Insufficient calcification of the bony thorax

• Circulating hormones (prostaglandins) that may affect cardiovascular

function

• Immature and fragile pulmonary vasculature

• Greater distance between functional alveoli and capillary bed, especially

in ELBW infants

Early Signs of Respiratory distress

Tachypnea

Nasal Flaring

Expiratory grunting

Central Cyanosis

Indicates poor oxygenation

Periodic Breathing

Respiratory pattern commonly seen in preterm newborns and is manifested by 5- to 10-second respiratory pauses followed by 10 to 15 seconds of compensatory rapid respirations.

Apnea

A cessation of respirations for 20 seconds or more, associated with hypoxia, bradycardia, or both.

Oxygen Therapy

The goals of oxygen therapy are to provide adequate oxygen to the tissues and prevent lactic acid accumulation resulting from hypoxia, yet avoid the potentially negative effects of oxygen therapy and baro trauma.

All methods of oxygenation require that the oxygen be warmed and humidified before entering the respiratory tract.

Current guidelines for Rescuscitation

Current resuscitation guidelines advocate the use of room air, as the initial gas, for infants greater than 35 weeks’ gestation and judicious use of oxygen when resuscitating preterm infants.

Preterm infants, particularly ELBW infants, lack a sufficiently developed antioxidant defense system

Heated Humified High flow Nasal Cannula

Provides oxygen at flow rates ranging from 1.5 to 8L/minute, supplying some positive pressure and greater oxygen concentrations when compared to conventional low-flow therapy

Alternating hypoxia and hyperoxia

Is known to be a proinflammatory stimulus

Continuous distending pressure (CPAP)

A form of respiratory support used for infants to keep their airways open.

Provides a positive pressure during both inspiratory and expiratory phases while the newborn spontaneously breathes and is delivered noninvasively using nasal prongs, nasopharyngeal tube, or face mask

Mechanical ventilation

A method of providing respiratory support for infants who cannot breathe adequately on their own.

It is indicated if the oxygen saturation of the blood cannot be maintained at a satisfactory level and the carbon dioxide level rises

Indication for Mechanical Ventilation

Whenever blood gas values reveal severe hypoxemia or severe hypercapnia.

May be required for the newborn with apnea, meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or congenital malformations.

Signs of Readiness to be Weaned from Ventilatory support

Blood gas results within an acceptable range and oxygen saturation levels maintained within normal limits.

A spontaneous, adequate respiratory effort must be present, and the infant must show sustained muscle tone during spontaneous respirations.

Weaning of Volume and Pressure Support

The infant may be extubated»»»»>placed on noninvasive respiratory

support »»»»»»»> and then weaned to oxygen alone.

What level to maintain oxygen saturation level of Extremely LBW

90 to 95%

Symptoms of Hypovolemia, Shock (or both)

Prolonged capillary refill (longer than 3 seconds)

Pale colour (pallor)

Poor muscle tone

Lethargy

Initial tachycardia then bradycardia,

Continued respiratory distress despite the provision of adequate oxygen and ventilation.

Hypotension may initially be present or may occur in some infants as a late sign of shock.

Umbilical Venous Catheter

Can be used to monitor newborn’s central venous pressure

Neutral Thermal Environment

An environment that permits newborn to maintain a normal core temperature with minimum oxygen consumption and calorie expenditure.

Hyperthermia

May be indicated by Apnea and flushed color

Preterm infants are not able to sweat, so they cant dissipate heat

Recommended for healthy term infants

36.5 to 37.5

Normal Axillary temperature for preterm or at risk newborns

36.3-37.2

Consequences of Cold stress to Newborns

Hypoxia

Metabolic acidosis

Hypoglycemia

Caring for Hypothermica Infant

Gradual rewarming to protect the brain

Skin to Skin (If infant condition allows)

Extreme hypothermia may require more rapid rewarming to avoid prolonged metabolic acidosis or hypoglycemia

Transition from the Isolette

Infants who are medically stable and gaining weight, tolerating enteral feedings, and weigh 1 300 to 1 500 g may be transitioned from the isolette.

The following guidelines may be followed to wean the infant from the isolette:

• Disconnect the servocontrol probe (if still in use).

• Dress the infant in a diaper, shirt, and cap.

• Lower the isolette temperature by 0.5°C every 2 hours.

• Record the temperature of the infant and the isolette.

• Assess the infant’s responses to the changes every hour until four

stable readings are obtained.

• Monitor the infant’s temperature and other vital signs.

This procedure is repeated until the isolette temperature is the same as the room temperature and the infant’s body temperature consistently remains within normal limits.

Breast milk via enteral feeding

Early introduction of small amounts of breast milk via enteral feedings

in metabolically stable preterm newborns is beneficial and has been shown to stimulate the newborn’s gastrointestinal tract, preventing mucosal atrophy and subsequent enteral feeding difficulties; improve developmental outcome; and prevent growth failure

Gavage feeding

A method of feeding infants through a tube inserted into the stomach (nasogastric/orogastric).

Gastrostomy feeding

A method of providing nutrition directly to the stomach via a surgically placed opening.

Special care must be taken to avoid a rapid bolus of the fluid because this may lead to respiratory compromise, abdominal distension, reflux into the esophagus, or diarrhea with malabsorption

Non-nutritive sucking

A practice where infants suck on a pacifier or finger without feeding, which can promote oral development.

May improve oxygenation and facilitate earlier transition to nipple feeding

Signs and Symptoms of Newborn INfection

Hypotthermia-most common

Central nervous system chanfes

Changes in color

Cardiovascular instability

Respiratory distress

Electrolyte imbalance

Decreased urine output

Pectin and hydrocolloid barriers

May be useful because these products mould well to skin contours and adhere in moist conditions.

Developmental care

A comprehensive term that encompasses strategies and interventions that are designed to reduce the effects of negative stress experienced by the newborn and optimize neurobehavioural development.

Respiratory Distress Syndrome

Represents a lung disorder usually affecting preterm infants.

Primary RDS is caused by surfactant deficiency, as the preterm infant does not have full lung maturity to produce adequate maintain lung alveoli open. The incidence and severity of RDS increase as gestational age decreases.

Factors that Place infants at increased risk for RDS

Lack of exposure to antenatal corticosteroids

Maternal diabetes

Perinatal infection

Caesarean birth without labour

Hydrops fetalis

Third-trimester bleeding

Conditions associated with a decrease in the incidence and severity of RDS

Female gender

Intrauterine growth restriction (IUGR), and

stressors such as

Maternal hypertension (gestational),

Maternal substance use

Chronic placental abruption

Prolonged rupture of membranes

Clinical Manifestation of RDS

• Tachypnea (=/>60 breaths/min) initially*

• Dyspnea

• Pronounced intercostal or substernal retractions

• Fine inspiratory crackles

• Audible expiratory grunt

• Flaring of the external nares

• Cyanosis or pallor

• Apnea

• With progression of condition, deteriorating vital signs, including blood pressure, apnea, body temperature instability

*Not all infants born with respiratory distress syndrome manifest these characteristics; very-low-birth-weight and extremely-low-birth-weight infants may have respiratory failure and shock at birth because of physiological immaturity.

Radiographic Characteristics of RDS

A diffuse granular pattern over both lung fields that closely resembles ground glass and represents alveolar atelectasis,

Dark streaks, or bronchograms, within the ground-glass areas that represent dilated, air-filled bronchioles

Low lung volumes

Supportive Measures for Favorable Outcomes in RDS

• Maintain adequate ventilation and oxygenation.

• Maintain acid–base balance.

• Maintain an NTE.

• Maintain adequate tissue perfusion and oxygenation.

• Prevent hypotension.

• Maintain adequate hydration and electrolyte status.

Persistent Pulmonary Hypertension

Occurs in infants of all gestational ages, including LBW infants.

A term applied to the combined findings of pulmonary hypertension and right-to-left shunting through fetal heart communications, in the context of a structurally normal heart.

Inhaled Nitric Oxide

Gas administered through the ventilator circuit, provides pulmonary vasodilation and reduces the pulmonary vascular resistance, leading to improved oxygenation.

Nursing Care for Infant Recieving iNO Therapy

Judicious monintoring of oxygen saturation levels. Typically >95%

Extracoporeal Membrane Oxygenation (ECMO)

High-frequency ventilation

Not typically used in infants less than 34 weeks’ gestation because the anticoagulant therapy required in the pump and circuits may increase the potential for IVH.

Patent Ductus Arterisosus

When the ductus arteriosus fails to close after birth

Clinical Manifestation of PDA

Systolic murmur

Active precordium

Bounding peripheral pulses

Tachycardia,

Tachypnea

Crackles on auscultation of air entry, and

Hepatomegaly.

Active precordium

Caused by an increased left ventricular stroke volume.

Necrotizing Enterocolitis

An acute inflammatory disease of the bowel with increased incidence in preterm infants.

It appears to occur in newborns whose gastrointestinal tracts have experiencedvascular compromise.

Intestinal ischemia of unknown etiology, immature gastrointestinal host defenses, bacterial proliferation, and feeding practices play a multifactorial role in the etiology

Preterm birth remains the most prominent risk factor for development

Clinical Manifestations of NEC

Abdominal distension

Bilious vomiting

Bloody stools

Abdominal tenderness

Erythema of the abdominal wall

The Post-term Infant

An infant born after 42 weeks of gestation, regardless of birth weight.

Meconium aspiration syndrome (MAS)

A condition in newborns caused by inhalation of meconium-stained amniotic fluid.

Gentle oropharyngeal suctioning

A technique used to clear the airway of a newborn, especially in cases of meconium aspiration.

Intubation if thick meconium

The procedure of placing a tube in the airway if the meconium is thick and obstructive.

Small for Gestational Age

Birth weight < 10th percentile on intrauterinemgrowth charts

Large for gestational age (LGA)

Infants whose weight is above the 90th percentile for their gestational age.

Clinical Manifestations of Infants of Diabetic Mothers

• Large for gestational age

• Very plump and full faced

• Abundant vernix caseosa

• Plethora

• Listless and lethargic

• Possibly meconium stained at birth

• Hypotonia

Symptoms of Hypoglycemia in Infants of DIabetc mothers

Jitteriness or tremors

Cyanotic episodes

Seizures,

Intermittent apneic episodes

Difficulties feeding

Nursing Care for Infants of Diabetic Mothers

Early examination for congenital anomalies, signs of possible respiratory or cardiac issues,

Maintenance of adequate thermoregulation

Early introduction of carbohydrate feedings as appropriate, and monitoring of serum blood glucose levels.