The High Risk Newborn

Who is at Risk?

• Low socioeconomic status of the mother.

• Limited access to healthcare or no prenatal care.

• Drug use or exposure to toxic chemicals.

• Pre-existing maternal medical conditions or pregnancy complications.

Newborn Classifications

• Micro preemie: Born before 26 weeks or less than 0.8 kg

• Preterm (preemie): 36 6/7 weeks (before 37 weeks)

• Late preterm: 34 to 36 weeks 6/7 weeks

• Term: 38 to 41 completed weeks

• Post-term: Greater than 42 weeks

Birth Weight Variations

• Large for gestational age (LGA): Above the 90th percentile growth curve or > 4.0 kg

• Small for gestational age (SGA): Below the 10th percentile growth curve or < 2.5 kg

• Very small for gestational age (VSGA): Below the 3rd percentile growth curve

• Low birth weight (LBW): < 2500 g

• Very low birth weight (VLBW): < 1500 g

• Extremely low birth weight (ELBW): < 1000 g

Large for Gestational Age Infant (LGA)

Macrosomia:

• Definition: Weight above 4 kg

• Infant of a Diabetic Mother: Large body, normal head circumference (H/C)

Potential Problems:

• Hypoglycemia and hyperinsulinemia

• Birth trauma: Shoulder dystocia, CNS injury

• Polycythemia

• Hyperbilirubinemia

• Poor feeding

• Thermal instability

Infant of a Diabetic Mother (IDM)

• Insulin does not cross the placenta.

• Glucose does cross the placenta.

• The fetus increases insulin production in response to the mother's high glucose levels.

• Hypoglycemia may occur at birth.

Symptoms of Hypoglycemia (1 to 2 hours post-delivery):

• Tremors/jitteriness

• Cyanosis

• Apnea

• Temperature instability

• Poor feeding

• Hypotonia

• Seizures

Interventions:

• Control maternal glucose levels

• Monitor for signs of hypoglycemia

• Early feeding (oral or IV if unable to feed orally)

• IV glucose: D10W if unable to PO

• Glucose monitoring q30 to 60 minutes until stable, then q24h and before each feeding

• Monitor electrolytes

• Assess for congenital anomalies

Small for Gestational Age Infants (SGA)

• Below the 10th percentile in weight or Intrauterine Growth Restriction (IUGR).

• Can apply to Preterm, Term, or Post-Term infants.

Appearance:

• Wasting

• Decreased fat stores

• Loose, dry skin

• Poor muscle tone

• Wide skull sutures

Potential Problems:

• Increased respiratory effort

• Hypoglycemia

• Polycythemia

• Cold stress

Term vs Preterm Neonate (picture)

Term >37 weeks

• Successfully adapts to the extrauterine environment.

• Pink at birth.

• Strong muscle tone and reflexes.

• Vigorous cry and respiratory effort.

• Normal respiratory rate.

• Normal cardiac rate and rhythm.

Preterm before 37 weeks

• Immature central nervous system and other systems.

• Thermoregulation problems.

• Hypoglycemia.

• Feeding problems.

• Posture lacks flexion.

• Decreased muscle tone (hypotonia).

• Skin thin and transparent.

• Lanugo (shed during the 7th to 8th month of gestation).

• Respirations: rapid, periodic breathing.

• Abdomen: soft, slightly rounded to scaphoid.

• Eyes: fused until 25 ½ to 26 ½ weeks.

• Ears: pinna flat without cartilage, folded.

Born after 42 weeks

• Can be SGA or LGA.

• Deep creases over soles of feet.

• Thick ear cartilage.

• No lanugo.

• Increased risk for meconium aspiration.

• Uteroplacental insufficiency.

• Increased mortality risk.

Intraventricular Hemorrhage

• Primarily related to prematurity.

• 90% occurs within the first 72 hours of life.

• Can cause long-term developmental delay.

Clinical Manifestations:

• Possibly none.

• Hypotonia.

• Increased heart rate (HR).

• Low blood pressure (BP).

Hypoxic-Ischemic Encephalopathy

Possible Causes:

• Intrauterine abruption.

• Cord issues.

• Resuscitation at birth.

Newborn Presentation:

• Limp.

• Cyanotic.

• Bradycardic.

• Apneic upon initial assessment.

Treatment:

• Head and body cooling.

Outcome:

• Outcome is variable and can lead to neurological impairment.

Meningocele/Myelomeningocele

• Meningocele: Protrusion of a sac that contains meninges and spinal fluid.

• Myelomeningocele: Sac-like cyst that contains meninges, spinal fluid, and a portion of the spinal cord and nerves.

Physical Assessment:

• Sensory/motor function depends on the location.

• Latex allergy.

• Possible loss of movement/sensation in the lower extremities.

• Neurogenic bladder/constant dribbling of stool.

• Clubbed feet are common.

• Repaired within 24 to 48 hours.

• May develop hydrocephalus after surgical repair; monitor head circumference.

Hydrocephalus

Clinical Presentation:

• Widened sutures

• Full/fontanelles

• Sunsetting eyes

• Vomiting, lethargy, irritability

• Visible scalp veins

• IVH (Intraventricular hemorrhage) can cause post-hemorrhagic hydrocephalus

• May occur after myelomeningocele closure

Treatment:

• EVT (Endoscopic Third Ventriculostomy)

• VAD (Ventricular Access Device)

• VP Shunt (Ventriculoperitoneal Shunt)

Educate Families on Shunt Malfunctions and Infections:

• Irritability, vomiting, increased head circumference, lethargy, change in feeding patterns.

Transient Tachypnea of the Newborn

• Most common in LGA, post-term, and C-section infants.

• Respiratory rate (RR) > 60, up to 80 to 100.

• Shortly after birth: grunting, nasal flaring, retractions, cyanosis.

• Improves within 12 to 72 hours.

Interventions:

• Supportive treatment, including IV fluids and supplemental oxygen.

Meconium Aspiration Syndrome (MAS)

Risk Factors:

• Post-term newborns

• Long labor

• Maternal smoking, diabetes, chronic cardiovascular disease, or hypertension

• Intrauterine growth restriction (IUGR)

Clinical Presentation:

• Tachypnea with rales

• Grunting, flaring, retracting, low Apgar scores

• Barrel-shaped chest

• Meconium-stained skin, nails, and umbilical cord

Interventions:

• If distressed:

  • Resuscitation with 100% oxygen

  • Direct tracheal suctioning (if decompensated)

  • Mechanical ventilation

  • High-frequency oscillation

  • Surfactant administration

  • Antibiotics for infection

  • Maintain pulmonary blood flow with volume expanders and vasopressors

  • Persistent pulmonary hypertension of the newborn (PPHN): nitric oxide, ECMO

Respiratory Distress Syndrome (RDS)

Surfactant deficiency and structural Immaturity.

Clinical Presentation:

• Tachypnea, grunting, flaring, retractions

• Poor lung compliance

• Hypotension

• Altered electrolytes

Interventions:

• Monitoring:

  • Cardiac monitors (CR)

  • Pulse oximetry (POX)

  • CO2 monitoring

• Correct acidemia and reduce hypoxemia

• Antenatal corticosteroids

• Supplemental oxygen and ventilation

• Exogenous surfactant:

  • Administered intra-tracheally via endotracheal tube (ETT)

• Monitor for pneumothorax and adjust ventilation as needed.

• Involve and inform the family (mother may still be receiving medical care).

Giving Surfactant/Curosurf

• The infant must be intubated; surfactant is given via endotracheal tube (ETT).

• Position the infant flat and midline.

• Pre-oxygenate and suction the infant.

• The initial dose is given in two aliquots.

  • Rapidly administer half of the total dose (one aliquot).

  • Immediately manually bag the patient for 1 minute.

  • Repeat with the second aliquot.

  • Immediately manually bag the patient for 1 minute.

• Do not rotate the patient from side to side; keep the infant flat and midline.

• Do not suction the patient for at least 1 hour after the dose is given.

Acceptable Oxygenation by Gestational Age (picture)

Bronchopulmonary Dysplasia (BPD)

• Definition: Chronic lung disease following neonatal lung injury.

• Causes: Barotrauma, Respiratory Distress Syndrome (RDS), Persistent Pulmonary Hypertension of the Newborn (PPHN).

Physical Assessment:

• Hypoxia

• Hypercarbia

• Growth failure

• Pulmonary hypertension

• Cor pulmonale and right-sided heart failure (HF)

Complications:

• Increased mortality

• Chronic respiratory infections

• Home oxygen therapy

• PPHN

• Fractures and rickets

• Neurodevelopmental sequelae

Management:

• Prevent development of BPD discharge.

• Prevent and manage hypoxia and hypercarbia.

• Use the lowest oxygen and ventilator settings tolerated.

• Administer corticosteroids

• Administer bronchodilators

• Provide chest physiotherapy (CPT), positioning, and suctioning.

• Nutrition: Ensure increased caloric intake,

• Address co-existing conditions like gastroesophageal reflux (GER), emesis, fatigue, and oral aversions.

• Provide emotional support, home care, and respite care.

Persistent Pulmonary Hypertension (PPHN)

Persistent Fetal Circulation (PFC):

• Definition: A right-to-left shunt away from the lungs and through the ductus arteriosus and patent foramen ovale (PFO), bypassing the lungs. This results in hypoxemia and acidosis, which stimulate pulmonary vasoconstriction and increase pulmonary vascular resistance (PVR).

Common Etiology:

• Hypoxia

• Asphyxia

• Bacterial sepsis

Treatment:

• Oxygenation

• Ventilation

• Nitric oxide (pulmonary vasodilator)

• Volume expanders

• Vasopressors

• Afterload reducers

• Hemodynamic support

• Extracorporeal Membrane Oxygenation (ECMO)

UAC/UVC

UAC (Umbilical Artery Catheter):

• Used to draw frequent blood samples and ABGs

• Continuously monitor blood pressure

• Monitor capillary refill in fingers, toes, and bottom

  • Alert the provider and prepare to pull the catheter if changes occur

UVC (Umbilical Venous Catheter):

• Inserted into the vein of the umbilical cord

• Used for IV fluids, nutrition, medications, and drips

Monitoring:

• Monitor UAC/UVC for bleeding and proper placement!

Patent Ductus Arteriosus (PDA)

• Definition: The fetal shunt between the left pulmonary artery and the descending aorta fails to close.

• Common in premature infants.

Symptoms:

• Unstable blood pressure

• Widened pulse pressure

• Bounding peripheral pulses

• Murmurs

• Increased oxygen requirement

• Swinging SpO2

• Metabolic acidosis

Interventions:

• Fluid restriction

• Diuretics

• Respiratory support

• Close the PDA

• Prostaglandin Synthase Inhibitors:

  • Indomethacin or Ibuprofen (current practice varies)

  • Acetaminophen (Tylenol)

• Surgical ligation

Feeding and Nutrition

Goal:

• Steady weight gain

Nutrition:

• High-calorie, high-protein formula supplemented with breast milk

• Vitamin supplements (e.g., Poly-Vi-Sol)

Enteral vs. Parenteral Nutrition:

• TPN/Lipids for parenteral nutrition

Feeding Methods:

• Gavage feeding for infants who are unable to suck effectively

• Bolus vs. intermittent feedings

• Non-nutritive sucking to stimulate sucking reflex

Breastfeeding:

• Breast milk is preferred

• Early feeding is encouraged

• Trophic feeds (small, stimulating feeds) or stimulus feeds for infants

Feeding Intolerance

Symptoms:

• Emesis

• Distension

• Bowel loops

• Decreased bowel sounds

• Irritability/lethargy

Indications:

• Necrotizing enterocolitis (NEC)

• Sepsis

• Acidosis

Necrotizing Enterocolitis (NEC)

Etiology:

• Unknown

Research suggests 3 mechanisms:

• Ischemia

• Bacterial colonization of the bowel

• Enteral feedings

Most common in infants <29 weeks gestation:

• Hypoxia

• Necrosis

• 90% of cases occur in preterm infants

• Mortality rate of 22%, which increases to 50% if surgical intervention is needed.

Assessment: Signs & Symptoms:

• Abdominal distension/shiny, discolored**

• Bilious emesis**

• Blood stools**

• Decreased bowel sounds

• Temperature instability

• Poor perfusion

• Metabolic acidosis/respiratory distress

• Hypotension

Radiographic Changes:

• Dilated bowel loops

• Pneumatosis intestinalis

Interventions:

• EMERGENCY!!

• Stop feedings immediately

• Decompress abdomen

• Frequent CBC/CMP

• Respiratory examination frequently

• Septic workup and antibiotics (possible perforation)

• Surgical resection or drain placement

Hyperbilirubinemia

Jaundice:

• Elevation of serum bilirubin levels which result in jaundice.

Types of Jaundice:

• Physiological Jaundice: Benign, caused by the breakdown of fetal red blood cells and an immature liver.

• Pathologic Jaundice: Results from an underlying disease, appears before 24 hours, or persists beyond 14 days.

• Acute Bilirubin Encephalopathy: Bilirubin deposits in the brain, potentially resulting in permanent damage.

• Kernicterus: Irreversible bilirubin toxicity that leads to severe cognitive impairments, hypotonia, and quadriplegia.

Risk Factors:

• Increased RBC production or breakdown

• Rh or ABO incompatibility

• Decreased liver function

• Prematurity

• Total serum bilirubin (TSB) at 12 hours <9.0

Assessments:

• Yellow skin, sclera, and mucous membranes

• Elevated bilirubin levels in labs

• Hypoxia, hypothermia, and hypoglycemia

Interventions:

• Monitor vital signs

• Phototherapy: Maintain eye mask, keep infant undressed, avoid lotions

• Monitor for Effects of Phototherapy: Dehydration, rash, bronze discoloration, elevated temperature

• Maintain/monitor fluid status

• Encourage parent bonding, explain phototherapy, and the reason for loose, greenish stools

• Possible exchange transfusion

Retinopathy of Prematurity

• Abnormal vascularization of the retina due to:

  • Too much oxygen causing damage, which leads to overgrowth or abnormal regrowth of blood vessels.

Risk Factors:

• Generally affects low birth weight (LBW) preterm infants.

Outcomes:

• Can lead to blindness if left untreated.

Prevention:

• Cautious use of oxygen** to avoid excessive oxygen levels that may contribute to retinal damage.

Treatment:

• Laser photocoagulation or Avastin (anti-VEGF treatment).

Apnea of Prematurity

• Definition: Apnea in newborns <37 weeks gestation, characterized by:

  • 20 seconds or longer or shorter periods if associated with cyanosis, pallor, or bradycardia.

Cause:

• Due to an immature CNS (central nervous system).

Incidence:

• Decreases with gestational age as the infant matures.

Interventions:

• Assessment and close monitoring of the infant.

• Prone positioning (if not contraindicated).

• Gentle stimulation (back or foot) to encourage breathing.

Documentation:

• Duration, heart rate (HR), and O2 saturation must be documented.

Nursing Care:

• Medications like caffeine or theophylline may be used.

• Respiratory support as needed.

• Family support and community care for ongoing care needs.

Neonatal Sepsis (Birth to 28 days)

Characteristics:

• Immature immune systems and inability to localize infections.

• Poor inflammatory response and ineffective phagocytosis.

• Lack of IgM immunoglobulin.

Assessment:

• May rapidly deteriorate within the first 12 hours post-delivery.

• Subtle behavioral changes:

  • Lethargy or irritability.

  • Color changes: pallor, dusky, cyanosis, mottling**.

  • Skin cool and clammy.

  • Temperature instability** (commonly hypothermia, rarely hyperthermia).

  • Tachycardia.

  • Later signs: apnea, bradycardia.

  • Feeding intolerance.

  • Vomiting, diarrhea, abdominal distension.

  • Poor suck or disinterest.

  • Hyperbilirubinemia.

Diagnostics:

• Comprehensive workup:

  • Aerobic and anaerobic blood cultures.

  • CSF culture.

  • Urine culture (suprapubic or sterile catheter).

  • Tracheal aspirate (if intubated).

  • Cultures from wounds or tubes.

• CBC with differential.

• CRP (C-reactive protein).

• Chest X-ray.

Interventions:

• Broad-spectrum antibiotic therapy as soon as cultures are obtained:

  • Ampicillin.

  • Cefotaxime (Claforan).

  • Zosyn.

  • Meropenem.

• Supportive care:

  • Respiratory support.

  • Hemodynamic support.

  • Nutritional support.

  • Metabolic management.

Prevention:

• Strict handwashing.

• Use of isolettes.

• Visitation restriction to unnecessary personnel.

• Clean equipment and incubators weekly.

• Aseptic technique.

• Supportive care:

  • Neutral thermal environment.

  • Respiratory support.

  • Cardiac care (monitor for anemia, hyperbilirubinemia, heart rate, blood pressure).

  • Nutrition.

  • Fluid and electrolyte balance.

Thermoregulation in Preterm Infants

• Big issue with preterm infants.

• High ratio of body surface area to body weight.

• Thinner, more permeable skin.

• Decreased ability to vasoconstrict.

Hyperthermia

• Elevated temperature

• Tachycardia

• Ruddy skin color

• Increased metabolism

• Always check temperature before calling the provider!

Hypothermia/Cold Stress

Manifestations:

• Color:

  • Pale

  • Acrocyanosis

  • Mottling

• Respiratory distress:

  • Nasal flaring

  • Apnea and/or bradycardia

• Behavior:

  • Lethargic/hypotonic

  • Feeble cry

  • Poor feeding

Interventions:

• Neutral Thermal Environment (isolette):

  • Servo control skin probe**

  • Radiant warmer

  • Double-walled isolette

  • Humidity**

• Other Interventions:

  • Use warm blankets/swaddling

  • Allow skin-to-skin care when possible

  • Keep the skin dry and cover the head with a cap

  • Cover the baby with plastic/polyethylene wrap**

  • Warm and humidify oxygen**

  • Use a skin probe to regulate temperature

Stress Cues

• Hiccupping

• Yawning

• Sneezing

• Frowning

• Looking away

• Squirming

• Frantic, disorganized activity

• Arms and legs pushing away

• Arms and legs limp and floppy

• Skin color changes

Ready to Interact

• Normal skin color

• Arms and legs flexed or tucked

• Hands touching their face

• Sucking

• Looking at you

• Smiling and appearing relaxed

• Regular breathing rate

• If the baby is on a monitor, a regular heartbeat

Developmental Care: Outcomes

Infant:

• Stress is reduced, and sleep time is increased.

• Promotes growth and development.

• Decreases ventilator/supplemental oxygen time.

• Results in more successful feeding.

• Improves neurodevelopmental outcomes.

• Reduces length and cost of stay.

Family/Caregiver:

• The family becomes a collaborator in the infant's care.

• Improves the family's emotional and social well-being.

Proper Positioning

• Neutral head position (to prevent misshapen head/torticollis).

• Rounded shoulders.

• Hips and knees flexed.

• Toes pointed straight.

• Hands to mouth.

• Boundaries provided appropriately.

• Mimic the fetal position (which is often lacking in preterm infants).

• Goal: Comfort and containment to promote development.

Family Centered Care

• The infant is viewed as an integral part of the family group.

• Care is directed at both the infant and the family.

• Care is provided through a collaborative relationship with the family.

• Encourage family presence, participation, and communication.

• Open visitation hours and policies that encourage visitation.

• Include the family in interdisciplinary conferences.

• Encourage the mother to pump and explain the benefits of breast milk for the baby's health.

• Skin-to-skin care.