At-Risk Newborn

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At-Risk Newborn

• Twila Brown, PhD, RN

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Who Is an At-Risk Infant?

• Risk of morbidity or mortality
• Prenatal and intrapartal risk factors
• Neonatal factors
• Gestational age
• Size
• Anticipate complications
• Assessments at birth - Apgar score

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High Risk Infant Overview of Class

• Congenital anomalies
• Characteristics and potential problems
• Preterm postterm
• Small for gestational age large for gestational
  age
• General concerns
• Thermoregulation
• Hypoglycemia
• Respiratory distress and complications
• Hyperbilirubinemia
• Psychosocial neonate family needs

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Congenital Anomalies Diaphragmatic Hernia

• Abdominal contents herniate through diaphragm
• Respirations are compromised
• Signs
• Respiratory distress and cyanosis
• Barrel shape chest, scaphoid abdomen
• Asymmetric chest expansion
• Absent breath sounds on effected side
• Bowel sounds in chest

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Congenital Anomalies Diaphragmatic Hernia

• Interventions
• Oxygen
• Respiratory support without over inflating
• Gastric decompression
• Head of bed elevated
• Turn to affected side
• ECMO
• Surgical repair

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Congenital Anomalies Tracheo-Esophageal Fistula

• Connection between the trachea and esophagus
• Proximal esophagus ends in blind pouch and distal
  esophagus joined to trachea
• Signs
• Increased oral secretions
• Coughs and choking
• Abdominal distention
• Not able to pass nasal or oral gastric tube
• Struggles with feeding

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Congenital Anomalies Tracheo-Esophageal Fistula

• Interventions
• Withhold feedings
• Elevate head of bed
• Suction to blind pouch to decrease aspiration
• Surgery

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Congenital Anomalies Neurotubular Defects

• Tissue protruding through vertebral column
• Meningocele
• Meningomyelocele
• Impairment
• Location and magnitude of defect determines
  extent of neuro impairment
• Sensory impairment follows motor, affects bladder
  and anal sphincter, contractures and deformities

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Congenital Anomalies Neurotubular Defects

• Intervention
• Pregnancy -- Folic acid and Alpha fetal protein
• Sterile, moist, normal saline dressing
• Prevent infection
• Decrease trauma
• Monitor for changes in fluid and heat loss
• Surgical repair, keep prone with legs flexed, no
  diaper over incision
• Long term hydrocephalus, wheelchair, braces,
  catheterization

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Congenital Anomalies Gastrocele and Omphalocele

• Gastroschisis
• Abdominal contents protrude through wall
• No sac covering intestines
• Omphalocele
• Abdominal contents protrude into umbilical cord
• Covered by translucent sac
• Associated with other anomalies

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Congenital Anomalies Gastrocele and Omphalocele

• Interventions
• Warm, moist, sterile dressing and plastic wrap
• Maintain hydration and temperature
• Position supine or side
• Gastric decompression
• Surgical repair
• Complications

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Congenital Anomalies Choanal Atresia

• Occlusion at nasopharnyx
• Signs
• Snorting respirations
• Difficulty breathing with feedings
• Cyanosis
• Interventions
• Assess patency of nares
• Maintain airway with oral airway
• Position with head of bed elevated

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Congenital Anomalies Cleft Lip and Palate

• Fissure involving nares, nasal septum, or
  connecting oral and nasal cavity
• Intervention
• Feedings with special nipples
• Feed upright and burp frequently
• Prevent aspiration
• Clean mouth after feedings

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Congenital Anomalies Heart Defects

• Signs
• Cyanosis
• Heart murmur
• Heart failure
• Most common defects
• Patent ductus arteriosus
• Ventricular septal defect
• Coarctation of the aorta
• Hypoplastic left heart
• Tetralogy of Fallot
• Transposition of the great vessels

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Substance-abusing Mother Fetal Alcohol Syndrome

• Facial abnormalities
• Behaviors
• Difficulty establishing respirations
• Sleeplessness - Jittery
• Hyperalert states - Hyper reflexes
• Inconsolable crying - Poor sucking
• Irritability - Lethargy

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Substance-abusing Mother Fetal Alcohol Syndrome

• Long-term complications
• Hypotonic and poor coordination
• Mental retardation or normal intelligence
• Speech and learning disabilities
• Hyperactivity and impulsivity
• Growth retardation
• Intervention
• Treat respiratory distress
• Reduce environmental stimulation
• Extra feeding time

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Substance-abusing Mother Drug Dependence

• Pregnant woman increased risk of
• Abruptio placentae, abortion, preterm labor,
  precipitous labor
• Neonate increased risk of
• Intrauterine asphyxia
• Respiratory problems
• Urogenital malformation
• Cerebrovascular complications
• Low birth weight and head circumference
• Drug withdrawal

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Substance-abusing Mother Drug Dependence

• Key assessment findings
• Tachypnea - Sensitive to stimuli
• High-pitched cry - Low birth weight
• Jitteriness - Hyperactive Moro reflex
• Poor sleeping - Increased reflexes
• Irritability - Diarrhea vomiting
• Interventions
• Swaddling - Calm environment
• Frequent feeding - Medication
• Promote bonding

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Inborn Error of Metabolism Phenyleketonuria
(PKU)

• Condition affects protein metabolism
• No enzyme to convert phenylalanine to tyrosine
• Affects development of brain and CNS
• Mental retardation if untreated
• CNS damage minimized if treatment before age 3
  months

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Inborn Error of Metabolism Phenyleketonuria
(PKU)

• Assessment
• Positive Guthrie test 24 hrs after feedings
• Failure to thrive - Microcephaly
• Vomiting - Hyperactivity
• Skin lesions - Irritability
• Repetitive motions
• Seizures and tremors
• Musty odor from skin and urine
• Intervention
• Low-phenylalanine formula
• Teach parents allowed foods in the diet

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Inborn Error of Metabolism Congenital
Hypothyroidism

• Enzymatic defect, lack of idodine in maternal
  diet, or maternal drugs can depress thyroid
  tissue
• Causes growth and mental retardation
• Assessment
• Large tongue Prolonged jaundice
• Umbilical hernia Poor feeding
• Mottled skin Low-pitch cry
• Large fontanelles Poor weight gain
• Hypotonia Delayed development
• Intervention Monitor thyroid medication

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Identification of At-Risk Newborns

• Gestational age
• Preterm
• Post-term
• Size of neonate
• Small for gestational age
• Large for gestational age

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Large for Gestational Age

• Birth weight at or above the 90th percentile
• Etiology
• Large parents
• Multiparous women
• Males larger than female
• Assessment findings
• Poor muscle tone and motor skills
• Difficult to arouse and maintain an alert state

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Large for Gestational Age

• Complications
• Birth trauma ceohalopelvic disproportion
• Asphyxia
• Meconium aspiration
• Polycythemia
• Hypoglycemia

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Infant of Diabetic Mother

• Severe diabetes associated with vascular
  complications may have small babies
• Mothers with classes A and C may have LGA
• High glucose stimulates fetal insulin increase
• Complications
• Hypoglycemia
• Hypocalcemia
• Hyperbilirubinemia
• Birth trauma

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Infant of a Diabetic Mother

• Complications
• Polycythemia
• Respiratory distress syndrome
• Congenital birth defects
• Interventions
• Test blood glucose
• Cord blood q hr X 4 q 4hr for 24 hrs
• If blood glucose is lt 40 mg/dl
• Feeding
• IV fluid of 10 dextrose water

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Small for Gestational Age

• Birth weight at or below the 10th percentile
• Intrauterine growth retardation
• Deficiency of nutrients through the placenta
• Poor nutrition
• Smoking or drug use
• Pregnancy induced hypertension
• Advanced diabetes
• Intrauterine infection

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Small for Gestational Age

• Physical characteristics
• Decreased subcutaneous tissue
• Loose skin
• Thin/dry umbilical cord
• Alert for size
• Dubowitz changes
• Problems
• Hypothermia
• Hypoglycemia
• Asphyxia
• Meconium aspiration

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Small for Gestational Age

• Problems
• Hypocalcemia
• Feeding difficulties
• Polycythemia
• Interventions
• Support respirations
• Provide neutral thermal environment
• Provide appropriate nutrition and hydration
• Monitor blood glucose levels
• Cluster care
• Provide skin care

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Post-term Infant

• Infant born after 42 weeks gestation
• Most continue to be well nourished
• Postmaturity syndrome
• Calcium deposits decrease placenta function
• Results in lack of oxygen and nutrients
• Physical characteristics
• Absent vernix and decreased lanugo
• Dry, cracked, parchment-like skin, peeling
• Hard, long nails
• Abundant scalp hair

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Post-term Infant

• Physical characteristics
• Loose skin
• Decreased subcutaneous fat
• Problems
• Hypothermia
• Hypoglycemia
• Asphyxia
• Meconium aspiration
• Polycythemia
• Interventions
• Supportive

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Premature Infant

• Born before the 37th week gestation
• Physical characteristics
• Skin is thin, smooth, shiny, with visible veins
• Minimal subcuatneous fat deposits
• Lanugo over body
• Minimal sole and palm creases
• Large head
• Ears have soft cartilage
• Genitals
• Posture is extended
• Reflexes absent or weak -- suck, gag

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Premature Infant

• Problems
• Hypothermia
• Hypoglycemia
• Respiratory distress syndrome
• Apnea and bradycardia
• Patent ductus arteriosus
• Hyperbilirubinemia
• Anemia
• Intraventricular hemorrhage
• Retinopathy of prematurity
• Necrotizing entercolitis

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Apnea Bradycardia

• Bradycardia heart rate less than 100 bpm
• Apnea not breathing for gt 15 to20 seconds
• Causes of apnea
• Obstructed airway
• Hypothermia or hyperthermia
• Hypoglycemia
• Sepsis
• Respiratory distress

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Apnea and Bradycardia

• Causes of apnea
• Anemia
• Hypercapnea
• Sepsis
• Hypocalcemia
• Seizure
• Vagal response
• Dehydration
• CNS depression
• Intraventricular hemorrhage

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Apnea and Bradycardia

• Interventions
• Tactile stimulation
• Suction airway
• Provide oxygen
• Provide mechanical ventilation
• Correct underlying cause
• Administer CNS stimulants
• Caffeine or theophylline

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Intraventricular hemorrhage

• Hemorrhage in the ventricles of the brain
• May cause motor deficits
• Hydrocephalus
• Sight and hearing loss
• Causes
• Capillary walls vulnerable to hypoxic events
• Hypoxia high CO2 dilates cerebral vessels
• Changes in intravascular pressure

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Intraventricular hemorrhage

• Signs
• May be no signs
• Bulging fontanel
• Signs of intracranial pressure
• Interventions
• Keep cerebral blood flow constant
• Prevent hypoxia
• Prevent increased blood pressure
• Elevate head of bed

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Anemia

• Causes
• Iron stored late
• Short life of RBC
• Blood drawing
• Hemorrhage
• Interventions
• Transfuse Packed red blood cells
• Iron suppliments and erythopoientin

• Signs
• Pallor
• Tachypnea
• Dyspnea
• Tachycardia
• Activity intolerance
• Feeding difficulty

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Retinopathy of Prematurity

• Progressive disorder of retina vessels
• Scar tissue and retina detachment
• Causes
• Fragile retinal vessels
• Fluctuating oxygen administration levels lead to
  rapid vasodilation and vasoconstriction
• Also occurs with hypoxemia, intraventricular
  hemorrhage, infection, acidosis, exposure to
  bright lights

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Retinopathy of Prematurity

• Interventions
• Decrease intracranial pressure
• Careful O2 administration
• Decrease lighting in NICU
• Eye exams
• May regress spontaneously
• Laser/cryosurgery
• Vitamin E

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Necrotizing entercolitis

• Cause
• Bowel eschemia during hypoxia
• Gas forming bacteria invade damaged cells of
  intestinal wall
• Cells rupture causing air in surface of bowel
• Damages bowel wall and causes bleeding
• Milk in bowel provides rich media for bacteria
  growth

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Necrotizing entercolitis

• Abdominal signs
• Pneumotosis in bowel wall
• Free air in abdomen if perforated
• Distended and shiny abdomen
• Gastric retention
• Blood in stools
• No bowel sounds
• Signs of sepsis

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Necrotizing entercolitis

• Interventions
• NPO
• Nasal gastric tube for decompression
• X-rays to follow deterioration of bowel
• Antibiotics
• Surgery resection of damaged portion
• Monitor for abdomen distension
• Hematest stools
• Long-term IV therapy
• Decrease O2 consumption

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Nutrition for the Preterm

• Inability to nipple feed until 35-36 wks
• Gag reflex
• Suck/swallow/breathe coordination
• Tires easily and worsens respiratory distress
• Require different composition of formula
• Increased metabolic rate
• Difficulty consuming calories
• Low iron and glycogen stores
• Equipment

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Nutrition for the Preterm

• IV total parenteral nutrition and lipids
• Gavage feedings
• Calorie requirement
• Fluid requirement
• High insensible water loss
• Urine output
• Signs of feeding intolerance

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References

• Littleton, L.Y., Engebretson, J.C. (2005).
  Maternity nursing care. Clifton Park, NY Thomson
  Delmar Learning.
• Olds, S.B., London, M.L., Ladewig, P.W.,
  Davidson, M.R. ( 2004). Maternal-newborn nursing
  womens health care (7th ed.). Upper Saddle
  River, NJ Prentice Hall.
• Silvestri, L.A. (2002). Saunders comprehensive
  review for NCLEX-RN (2nd ed.). Philadelphia W.B.
  Sanders.
• Straight As in maternal-neonatal nursing.
  (2004). Philadelphia Lippincott Williams
  Wilkins.