Week 15: High Risk Newborns and Associated Care

High-Risk Neonate

• A neonate is classified as high risk if there is an increased chance of dying during or shortly after birth.

• Advances in medicine have improved survival rates and outcomes for high-risk infants.

• General trends in how families cope with the unexpected challenges of caring for high-risk infants.

Common Complications and Anomalies

• Types of Anomalies:

  • Congenital defects

  • Cognitive delays

• Maternal Infections and their adverse impact on fetal development.

• Importance of Early Interventions to prevent or treat complications.

Assessment of Vital Functions

• Follow ABCs in care:

  • A: Ensure oxygenation and ventilation

  • B: Thermoregulation

  • C: Nutrition and fluid/electrolyte balance

• Prevention and control of infection are paramount.

• Encouragement of parental bonding and providing developmental care.

Preterm Delivery

• Risk factors: Preeclampsia, maternal diseases, multiple pregnancy, substance use/smoking, and lack of prenatal care.

• Symptoms: Temperature instability, hypoglycemia, hyperbilirubinemia, and increased risk of infection.

• Treatment: Prioritize cardiac and respiratory support; maintain body temperature (daily weight, maintain temp, 3-5 days without apnea/bradycardia events).

• Complications: Respiratory Distress Syndrome (RDS), intraventricular hemorrhage, retinopathy of prematurity, and necrotizing enterocolitis (NEC).

• Nursing Management: Perform resuscitative measures and respiratory support. Preterm infants under 34 weeks often require gavage feedings; nonnutritive sucking with a pacifier aids transition to oral feeding.

Newborn Infection/Sepsis

• Infection can be contracted before, during, or after delivery.

• Culture, nasal swab, and lumbar puncture.

• Organisms: S. aureus, E. coli, H. influenza, S. epidermis, GBS.

  • GBS: on IV antibiotics for 21 days in the hospital.

• Risk Factors:

  • PROM, TORCH infections, Preterm, Low birth weight, Prolonged labor, Meconium aspiration, Maternal UTI & STIs, and HIV.

• Expected Findings: Temperature instability, poor feeding, hypo/hyperglycemia, abd. distention, color change, N/V, lathergy, abnormal BI, drainage from eye, umbilical or stump.

Assessment at 24 Hours of Life

• Difficulty establishing respirations

• Irritability

• Lethargy

• Seizure activity

• Tremulousness

• Opisthotonos (hyperextension)

• Poor sucking reflex

• Abdominal distention

• Flat philtrum (middle upper lip)

• Wide-set eyes

Neonatal Substance Withdrawal

• Maternal substance use (e.g., alcohol, drugs) can lead to Neonatal Abstinence Syndrome (NAS):

  • Involves withdrawal symptoms in newborns, leading to neurobehavioral and physical changes.

  • Dependence on the type of substance used, dosage, and timing of exposure.

    • Substances include (and are not limited to): Opioids, Barbiturates, Benzodiazepines, SSRIs, caffeine, and nicotine.

• Intreauterine drug expose can cause neurobehavioral changes, anomalies, and evidence of withdrawal in the neonate.

• Diagnostics: Obtain specimends of urine and meconium.

  • Meconium can detect drug use over a 20-week period and is currently the best method for detecting drug exposure.

S/S of NAS

• Symptoms observed 24-72 hours post-birth include:

  • CNS hypersensitivity: Shrill/High-pitched cry, hyperactivity, seizures

  • Autonomic dysfunction: Temperature instability (typically higher), respiratory distress

  • Poor feeding behaviors, GI disturbances (loose stool)

Risk Factors for NAS

• Pregnant Women who use addictive drugs are at higher risk for:

  • Abruptio placentae, Spontaneous abortion, Preterm labor, Precipitous labor, and Mental health issues

• Neonatal Complications may include:

  • Urogenital malformations, Cerebrovascular complications, Low birth weight, Decreased head circumference, Respiratory complications, Sezuires, Failure to thrive, and Death

Treatment of NAS

• Inital treatment is supportive care.

• Symptomatic treatment in a controlled environment:

  • Quiet, low-stimulus settings, pacifiers, swaddling.

  • Medication options include methadone or morpine+phenobarbital, with careful tapering.

  • Give low lactose formula due to sensitivity.

  • Provide respiratory care as needed.

• Supporting gradual withdrawal while ensuring proper nutrition and hydration.

Findings that Indicate Need for Drug Testing

• Maternal:

  • Lack of prenatal care

  • Previous unexplained fetal demise

  • Precipitous labor

  • Altered nutrition

  • Abruptio placenta

  • HTN episodes

  • Severe mood swings

  • Recurrent spontaneous abortions

• Fetal:

  • Preterm labor

  • Cardiac defects

  • Unexplained IUGR

  • Neurobehavioral abnormalities

  • Urogential anomalies

Fetal Alcohol Syndrome (FAS)

• Caused by any alcohol intake during pregnancy; NO amount is safe.

• Characteristics: High-pitched cry, difficulty soothing, growth restriction, craniofacial anomalies, and CNS dysfunction.

• Long-term risks: Include congenital defects (e.g., ADHD, low IQ) and various neurological impairments (e.g., mental retardation, poor coordination).

• Diagnosis: Requires documentation of three specific facial abnormalities, growth deficits, and CNS structural/functional abnormalities.

• Complications: Cardiac murmurs, limited joint movement, kidney defects, and cognitive difficulties (memory, attention, learning disabilities).

• Treatment: Primarily supportive, focusing on prevention, respiratory care, and ensuring adequate nutrition and bonding.

Finnegan Scoring System

• Used to assess the severity of withdrawal every four hours (the higher the score, the higher need for medication).

• Constant monitoring for signs of distress, including seizures, weight loss, and feeding difficulties.

• Detailed scoring will guide medication administration and weaning strategies.

Assessment of Withdrawal

• W: Wakefulness

• I: Irritability

• T: Temperature variations with tachycardia, tremors (3 Ts)

• H: Hyperactivity with high-pitched cry, hyperreflexia, hypertonia

• D: Diarrhea, diaphoresis, disorganized sucking reflex

• R: Respiratory distress

• A: Apneic events, autonomic dysfunction

• W: Weight loss/failure to gain weight

• A: Alkalosis

• L: Lacrimation (flow of tears)

Complications of Neonatal Withdrawal

• Risks associated with maternal drug use include:

  • Low birth weight

  • Increased rates of sudden infant death syndrome (SIDS)

  • Neurobehavioral issues

Hypoglycemia

• Definition: Blood glucose < 30 mg/dL (normal is 30-60 mg/dL) within the first three days for term newborns.

• Possible causes include a lack of adequate glucose production following umbilical cord clamping, increased physiological stressors.

• Assessment/Symptoms: Jitteriness, weak cry, irritability, lethargy, and respiratory irregularities.

• Management includes:

  • Regular heel-stick glucose checks

  • Oral feeding for asymptomatic newborns, IV dextrose for symptomatic ones.

  • Oral/gavage/parenteral feeding to increase glucose.

  • Maintain skin-to-skin for thermoregulation.

Respiratory Distress Syndrome (RDS)

• Risk factors:

  • Primarily seen in preterm infants due to immature lung development.

    • Carries long-term respiratory and neurologic complications.

  • Characterized by inadequate surfactant production.

    • Surfactant: A substance composed of lipids and proteins that reduces surface tension in the alveoli, helping to prevent their collapse during exhalation and allowing for easier breathing.

  • Maternal diabetes and stress during delivery that produce acidosis in the neonate.

• Expected findings and clinical manifestations:**

  • Expiratory grunting, retractions, labored breathing, and cyanosis.

  • RDS can lead to atelectasis, increased work of breathing, respiratory acidosis, and hypoxemia.

  • At risk of developing asthma, pneumothorax, and intraventricular hemorrhage.

Treatment for RDS

• Supportive care includes maintaining body temperature, oxygen supplementation, and potentially mechanical ventilation.

  • Some are on BiPAP or CPAP.

  • Parenteral feedings (gavage/oral feedings are not recommended due to high oxygenation needs).

• Administration of surfactant should occur via an endotracheal tube, with careful monitoring thereafter.

  • Assess endotracheal tube placement.

Meconium Aspiration Syndrome

• Occurs when meconium is inhaled (typically in utero or at first breath), causing airway obstruction and inhibiting surfactant production.

• Symptoms: Cyanosis, rapid/labored breathing, low Apgar scores.

• Risk Factors: Maternal diabetes, HTN, fetal distress, advanced gestational age.

• Testing: Coarse/crackly breath sounds, ABG, chest x-ray.

• Management: Suctioning (mouth/nose first), respiratory support (e.g., oxygen, mechanical ventilation), chest physiotherapy, antibiotics.

• Complications: Aspiration pneumonia, bronchopulmonary dysplasia, cerebral palsy, pneumothorax, PPHN.

Types of Jaundice

• Physiologic vs. Pathologic

  • Physiologic resolves in 7-10 days; pathologic requires further investigation if present within the first 24 hours or persists longer than two weeks (clinical jaundice that occurs past 14 days; vice versa for physiologic).

Hyperbilirubin

• Jaundice normally appears on the head (sclera/mucus membranes), then progresses down to the thorax, abdomen, and extremities.

• Testing: done by direct or indirect bilirubin levels.

  • Levels that are excessively elevated or vary daily suggest a pathologic process.

• Causes: requires patient and family history of blood disorders for incompatibilities.

• Treatment options include phototherapy (use eye protection and cover genitalia) and exchange transfusions (albumin assists with binding; IV globin is done for isoimmune hemolytic disease) for severe cases to prevent kernicterus.

• Complications:

  • Acute bilirubin encephalopathy (bilirubin deposited in the brain)

  • Kernicterus (levels >25 mg/dL, toxicity)

Nursing Management for Phototherapy

• Continuous education around feeding and eye protection during phototherapy.

• Importance of follow-up labs to monitor bilirubin levels post-discharge.

• Observe effects of phototherapy.

• Bronze discoloration: not a serious complication

• Maculopapular skin rash: not a serious complication

• Dehydration: poor skin turgor, dry mucous membranes, decreased urinary output.

• A newborn may have loose, green stool (containing bile).