Newborn at Risk

Healthy Newborns

  • To assess sick newborns, understanding healthy newborns is crucial.

  • Key aspects include vital signs and breathing patterns.

  • Chapter 15 provides a good review.

Chapter 17: Complications

  • Focus on neuromuscular or muscular dysfunction.

  • Assessment of the spine in newborns is important.

Alpha Fetoprotein (AFP) Test

  • Prenatal blood test around 15-17 weeks of pregnancy.

  • Screens for brain and spinal cord problems.

  • Abnormal alpha fetoprotein levels indicate potential issues, e.g., neural tube defects.

  • Abnormal levels prompt further tests like ultrasounds.

  • Folic acid is essential for brain and spinal cord development.

  • Alpha fetoprotein is a chemical released from the fetus' spinal cord into the mother's bloodstream if there are abnormalities.

Definitions (Box 34)

  • Anencephaly: Congenital malformation with absent cerebral hemispheres.

    • Infants may survive in utero but have limited survival after birth (e.g., respiratory distress, sepsis).

    • Deficiency in folic acid can cause.

  • Meningocele: Hernial protrusion of meninges filled with spinal fluid.

  • Myelomeningocele: Hernial protrusion containing meninges, spinal fluid, and a portion of the spinal cord with nerves (most severe).

Neural Tube Defects/Spina Bifida

  • Failure of the spine to close properly.

  • Vertebrae protect the spinal cord.

  • Insufficient folic acid can lead to defects.

Types of Spina Bifida:

  • Occulta: Mildest form; may present as a dimple or tuft of hair on the lower spine.

  • Meningocele: Sac-like cyst containing meninges and spinal fluid.

  • Myelomeningocele: Most severe; sac includes spinal cord and nerves.

  • The goal is prevention through sufficient folic acid intake.

High-Risk Newborns

  • Prematurity and low birth weight are significant causes of infant death.

  • Congenital malformations are the leading cause.

    • Examples: anencephaly, spina bifida, cleft lip/palate.

Infant Mortality

  • Definition: Death of a baby between one day and one year of age.

  • Indicator of community health, socioeconomic status, healthcare quality and availability.

  • Afghanistan has the worst infant mortality rate globally.

  • In 2017, over 22,000 infants died in the US.

Infant Mortality in St. Louis County (2018)

  • 386 infant deaths.

  • Leading causes include short gestation, low birth weight, congenital malformations, accidents.

  • Infant mortality rates are higher in St. Louis County compared to the United States (2019).

  • Disparities exist based on geographic location and socioeconomic status.

  • There are efforts to reduce infant mortality rates in St. Louis County.

  • Nurses for Newborns is an organization making home visits to high-risk areas and following babies from birth until two or three years of age to improve and decrease infant mortality in St. Louis County.

Factors Indicating High-Risk Newborn

  • Factors present at birth

  • Maternal age and parity (too young or over 35).

  • Chronic medical conditions.

  • Gestation period (ideally 38-42 weeks).

  • Birth weight.

Classifications

  • AGA (Appropriate for Gestational Age): between 10th and 90th percentile.

  • SGA (Small for Gestational Age): Weight less than 10th percentile.

  • LGA (Large for Gestational Age): Weight greater than 90th percentile.

  • IUGR (Intrauterine growth restriction): fetus is too small while in utero

  • Macrosomia: fetus is too big while in utero

SGA (Small for Gestational Age)

  • Weight is less than the tenth percentile for gestational age; not necessarily preterm.

  • Potential causes include hypertension, placental issues, poor nutrition, drug abuse, and smoking.

  • Nicotine is an appetite suppressant that could cause SGA.

  • Complications: Hypoglycemia.

LGA (Large for Gestational Age)

  • Often associated with diabetic mothers.

  • Concerns: Birth trauma (e.g., shoulder dystocia), Erb's palsy, hypoglycemia, polycythemia.

  • Excessive insulin acts as a growth hormone in fetus.

  • C-sections may be necessary.

Potential Nursing Diagnoses for LGA Baby

  • Impaired gas exchange (delayed surfactant production).

  • Risk for injury.

  • Imbalanced nutrition.

Post-Term Newborns

  • Born after 42 weeks.

  • Characteristics: Dry, cracking skin; long fingernails.

  • Placenta may calcify, increasing risk of impaired gas exchange.

  • Amniotic fluid should be clear; meconium-stained fluid indicates fetal hypoxia.

  • Meconium aspiration can lead to meconium aspiration syndrome.

Preterm Neonates

  • Viability (ability to survive outside the uterus) typically occurs around 23 weeks gestation, 500 grams.

  • Potential causes: Preeclampsia, intrauterine growth restriction, placenta previa, incompetent cervix.

  • Preterm birth rate is rising.

  • Premature babies are different from SGA babies.

Risks factors of preterm labors (page 549)

  • Non modifiable and treatable

  • >35 years of age and <17

  • Unplanned pregnancy

  • Domestic violence (abruption)

  • Drug use

  • Life stress

  • IVF

  • Low pre pregnancy weight or obesity

Complications

  • Require surfactant to help them breathe better, keeps the alveoli open.

  • Increased morbidity from vaccine-preventable diseases.

Psychosocial Needs

  • Families with high-risk newborns need support.

  • Promote parent-newborn attachment as much as possible.

  • Automatic risk for postpartum depression.

  • Stress from dysfunctional family processes and parenting.

Neonatal Problems Associated with Chapter 17

  • Intraventricular hemorrhage

  • Retinopathy of prematurity

  • Meconium aspiration syndrome

  • Hyperbilirubinemia.

Hyperbilirubinemia

  • Goal: Prevent neurologic sequelae (destruction of nerve cells).

  • Screening at 24 hours of age.

  • Pathologic vs. Physiologic jaundice.

  • Rh-negative and O blood type in mom's increases the pathologic risk.

Management

  • Phototherapy is common treatment for both types of Jaundice.

  • Increased fluid intake.

  • Phototherapy side effects: Eye damage, dehydration.

  • Do not apply lotion during phototherapy.

  • Caput succedaneum or cephalohematoma may increase risk.

    • Caput cicadium -> no blood

    • Cephalohematoma -> blood

Nursing Hypotheses for Elevated Bilirubin

  • Risk for injury.

  • Risk for fluid volume deficit.

  • Peripheral neurovascular dysfunction.

  • Impaired parenting.

Neonatal Infections

  • All newborns are at risk due to compromised immune systems.
    * Encourage breastfeeding

  • Group B Strep (GBS) positive mothers need antibiotics during labor to protect the fetus.

Types

  • Early Onset, Late Onset, Very Late Onset.

  • Risk Factors: Lack of prenatal care, GBS-positive mother.

Manifestations of Infection

  • Inability to maintain temperature (decreased temp).

  • Poor feeding.

  • Tachypnea.

  • Lethargy, poor tone (baby is flexed).

  • Hyper vigilance with assessing your newborns.

Respiratory Distress Syndrome (RDS)

  • Prematurity or surfactant deficiency.

  • Hypoxia, respiratory acidosis, metabolic acidosis.

  • Tachypnea, grunting, low O2 saturation.

Management

  • Prevent Preterm birth.

  • Glucocorticoids (betamethasone, dexamethasone) enhance fetal lung development.

  • Postnatal surfactant therapy via ET tube.

Nursing Hypotheses

  • Ineffective breathing pattern.

Hypoglycemia

  • Blood sugar less than 40 mg/dL.

  • Risk of neurological deficits if untreated.

  • Interventions: Donor breast milk, early breastfeeding, skin-to-skin contact.

  • Do not orally feed tachypneic infants (risk of aspiration).