High-Risk Newborn Lecture Notes

HIGH-RISK NEWBORN

Presenter Information

  • Name: Debbie Amason, DNP, RN
  • Course: High-Risk Newborns

Terms to Know

  • Asphyxia: A condition arising when the body is deprived of oxygen, causing unconsciousness or death.
  • Retinopathy of Prematurity: A potentially blinding eye disorder that predominantly affects premature infants.
  • Overstimulation: An excessive amount of sensory input that can lead to stress responses in infants.
  • Apnea: A pause in breathing that lasts 20 seconds or longer or a shorter pause associated with bradycardia.
  • Kangaroo Care: A method of holding a premature or low-birth-weight infant by skin-to-skin contact, promoting bonding and health benefits.
  • Post-term: Infants born after 42 weeks of gestation.
  • Meconium Aspiration: A condition where a newborn inhales a mixture of meconium and amniotic fluid into the lungs around the time of delivery.
  • Neonatal Abstinence Syndrome: A withdrawal syndrome seen in newborns exposed to drugs while in utero.
  • Respiratory Distress Syndrome (RDS): A condition in which the lungs can't provide enough oxygen due to insufficient surfactant production.
  • Preterm: An infant born before 37 weeks of gestation.
  • Late Preterm: Infants born between 34 and 36 weeks of gestation.

Definition of High-Risk Newborns

  • High-Risk Newborn:
       - Has an increased chance of dying.
       - May have a congenital or perinatal problem.
       - Requires prompt intervention in a Neonatal Intensive Care Unit (NICU) where life-support capacities can be provided.

General Considerations

  • Risk Factors: While many risks and conditions primarily pertain to preterm infants, any newborn, regardless of gestational age, can experience these conditions.
  • Exemplars of High-Risk Newborn Conditions:
      - Respiratory Distress Syndrome (RDS)
      - Neonatal Abstinence Syndrome
      - Neural Tube Defects
      - Meconium Aspiration Syndrome

Preterm Neonate

  • Definition: Classic high-risk neonate born after 20 weeks and before the beginning of the 38th week of gestation.
  • Classification:
      - Preterm: Born after 20 weeks but prior to 38 weeks.
      - Low Birth Weight (LBW): Weighs less than 2500 grams (5 lb 8 oz).
      - Very Low Birth Weight (VLBW): Weighs less than 1500 grams (3 lb 5 oz).
      - Extremely Low Birth Weight (ELBW): Weighs 1000 grams or less (2 lb 3 oz).

Physical Characteristics of Preterm Neonates

  • Weight less than 5.5 pounds
  • Scrawny appearance with poor muscle tone
  • Minimal subcutaneous fat
  • Undescended testes
  • Plentiful lanugo (fine hair)
  • Poorly formed ear pinna
  • Fused eyelids
  • Soft, spongy skull bones
  • Matted scalp hair
  • Minimal creases in soles and palms
  • Thin, transparent skin
  • Abundant vernix (protective skin coating)

Late Preterm Infants

  • At Risk For:
      - Respiratory disorders
      - Poor thermoregulation
      - Hypoglycemia
      - Jaundice
      - Feeding problems relating to immature suck and swallow
      - Acidosis
      - Sepsis

  • Contributing Factors:
      - Difficulty in determining estimated due date (EDD)
      - Multifetal pregnancy
      - Maternal obesity
      - Assisted reproductive techniques
      - Elective induction
      - Cesarean delivery
      - Advanced maternal age (AMA)

Nursing Care for Late Preterm Infants

  • Thermoregulation:
      - Check temperature as per protocol
      - Provide radiant warmer or isolette
      - Implement Kangaroo care (skin-to-skin contact)
  • Nutrition:
      - Feed every 2-3 hours
      - Consider NG (nasogastric) feeding if oral feeding is difficult
      - Acknowledge difficulty in latching for feeding

Respiratory Problems in High-Risk Newborns

  • Causes of Respiratory Issues:
      - Lack of surfactant contributing to RDS
      - Poor cough reflex, narrow respiratory passages, and weak muscles leading to increased respiratory distress.
  • Management and Positioning:
      - Use prone and side-lying positions to enhance respiratory secretion drainage, increase oxygenation, and reduce energy expenditure.

Thermoregulation Challenges

  • Heat Loss in Preterm Infants:
      - Skin characteristics include thinness with blood vessels near the surface, insufficient brown fat for heat production, and minimal insulation from white fat.
      - Large surface area exacerbating heat loss due to extended extremities and immature temperature control centers.
  • Indicators of Inadequate Temperature Regulation:
      - Axillary temperature ≤ 97.3 or ≥ 98.4
      - Abdominal skin temperature ≤ 96.8 or ≥ 97.7
      - Poor feeding or feeding intolerance
      - Signs of irritability or lethargy
      - Decreased muscle tone
      - Pale, cool to touch skin, mottled or acrocyanotic
      - Respiratory distress and poor weight gain
      - Weak cry or suck, hypoglycemia

Neutral Thermal Environment (NTE)

  • Importance: Helps prevent the need for increased oxygen levels to maintain body temperature.
      - Warm delivery room required: dry infant immediately, consider skin-to-skin contact.
      - For infants ≤ 29 weeks, consider wrapping or using a warming bag.
      - Use incubators or warmed air when necessary, while monitoring for overheating.

Environmental Stress in Preterm Infants

  • Infants may indicate overstimulation through changes in oxygenation and behavior.
  • Care Strategies: Schedule touch times, reduce stimuli, and promote adequate rest to prevent overstimulation.

Signs of Overstimulation

  • Oxygenation Changes:
      - Vital signs instability
      - Cyanosis, pallor, mottling
      - Nasal flaring and decreased O2 saturation
      - Sneezing or coughing
  • Behavior Changes:
      - Stiff and extended arms, fisting of hands
      - Alert, worried expression and gaze aversion
      - Regurgitation, gagging, hiccupping, yawning, and fatigue signs such as arching.

Post-term Infants

  • Definition: Infants born after 42 weeks of gestation, often due to placental insufficiency.

  • Nursing Assessment:
      - Common characteristics include dry, cracked, or wrinkled skin; possibly meconium-stained.
      - Infants may present with long, thin extremities, long nails, creases covering the entire soles of the feet.
      - Observational signs include wide-eyed alertness, abundant hair on the scalp, thin umbilical cords, and reduced vernix and lanugo.

  • Concerns for Post-term Infants:
      - Risks of hypoxia and malnourishment due to placental dysfunction.
      - Possible complications include meconium aspiration and polycythemia.
      - Nursing Observations include signs of respiratory distress, blood glucose checks, early feedings, temperature maintenance, and jaundice monitoring.

Nursing Management for High-Risk Newborns

  • Essential Aspects:
      - Oxygenation support
      - Thermal regulation measures
      - Nutrition and fluid balance strategies
      - Infection prevention protocols
      - Stimulation levels appropriate to developmental needs
      - Pain management
      - Monitoring growth and developmental progress
      - Providing parental support, especially considering high-risk status or potential perinatal loss
      - Discharge preparation includes education and support for families.

High-Risk Respiratory Complications

  • Conditions:
      - Asphyxia
      - Meconium Aspiration Syndrome (MAS)
      - Respiratory Distress Syndrome (RDS)

Neonatal Resuscitation Protocols

  • Responsibilities:
      - Ensure equipment is ready and functioning.
      - Train personnel for emergency procedures.
      - Assist healthcare providers with:
        - Intubation
        - Insertion of umbilical catheters
        - Medication administration.

Perinatal Asphyxia

  • Definition: Newborn fails to initiate adequate, sustained respirations post-birth, leading to impaired gas exchange and acidosis.
  • Common Risk Factors: Detail not provided.

Respiratory Distress Syndrome (RDS)

  • Overview: Insufficient surfactant production results in respiratory trouble and impaired gas exchange.
  • Signs and Symptoms: Include grunting, nasal flaring, retractions, apnea, tachypnea, escalating oxygen requirements, carbon dioxide retention, cyanosis, and abnormal respiratory findings within the first 8-10 minutes post-birth.
  • Management Approaches: Minimal stimulation, maintaining warmth, IV fluids or parenteral nutrition, mechanical ventilation, administering exogenous surfactant (e.g., Survanta, Exosurf).

Meconium Aspiration Syndrome (MAS)

  • Impact: Causes airway obstruction, pneumonitis, and air trapping; newborns at high risk have thick meconium in amniotic fluid.
  • Diagnosis: Utilize chest x-ray and arterial blood gases (ABGs).
  • Management Strategies: Ensure adequate tissue perfusion, use cluster care, maintain NTE, monitor blood pressures and blood volumes, administer antibiotics, and consider sedation. If unsuccessful, extracorporeal membrane oxygenation (ECMO) may be necessary.

Neonatal Abstinence Syndrome (NAS)

  • Substances Involved: Common substances include tobacco, alcohol, marijuana, opioids, methamphetamines, and cocaine.
  • Definition: Drug dependency acquired in utero, presenting with neurological and physical symptoms.
  • Statistical Insight: In 2012, 21,732 babies were born with NAS, highlighting a significant increase compared to earlier years. The average length of hospitalization for affected newborns is approximately 16.9 days, costing around $66,700.

Symptoms of Neonatal Abstinence Syndrome

  • Symptoms can be classified into CNS, Respiratory, and Gastrointestinal:
      - CNS Symptoms: Tremors, seizures, hyperactive reflexes, restlessness, hypertonic muscles, shrill high-pitched cry, disturbed sleep patterns.
      - Respiratory Symptoms: Mottling of skin, sweating, frequent sneezing, nasal flaring or retractions, tachypnea, apnea.
      - Gastrointestinal Symptoms: Poor feeding, frantic sucking, watery stools, projectile vomiting.

Modified Finnegan's Scoring Tool

  • Used for assessing the severity of withdrawal in newborns, with specific criteria to evaluate multiple symptoms.

Spina Bifida

  • Definition: Congenital neural tube defect characterized by incomplete closure of the vertebrae.
  • Types:
      - Spina Bifida Occulta: Does not involve herniation of spinal cord or meninges.
      - Spina Bifida Cystica: Involves a saclike protrusion.
  • Clinical Manifestations: May present as tuft of hair or dimple in the lower lumbar area.
  • Causes: Unknown, with confirmed risk related to maternal folic acid deficiency. Genetic predispositions are also considered.

Hydrocephalus

  • Overview: Occurs due to an imbalance of cerebrospinal fluid (CSF) production and absorption.
  • Symptoms: Enlarged ventricles, increased intracranial pressure, and abnormally large head circumference.
  • Treatment: Involves placing ventriculoperitoneal shunts to manage CSF accumulation.

Family Care Considerations

  • Parenting Support:
      - Address fears due to extended hospital stays.
      - Foster bonding by encouraging physical interaction and naming the infant.
      - Promote positive communication about their child's care.
  • Preparations for Discharge:
      - Advance care for parents during hospital stays is crucial, including support during visits, disseminating valuable information, and encouraging Kangaroo care.

Kangaroo Care

  • Definition: A method of holding an infant that promotes skin-to-skin contact, fostering bonding and physiological stability for the infant.