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Introduction to Neonatal Care

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Title: Care of the Compromised Neonate Author: Rhona K Williams Last modified by: Dr Jeremy Jolley Created Date: 3/21/2007 3:14:34 PM Document presentation format – PowerPoint PPT presentation

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Title: Introduction to Neonatal Care


1
Introduction to Neonatal Care
2
Learning outcomes
  • Explain how the needs of the baby differ from
    those of an older child
  • Describe the basic care needs of the baby
  • Identify some common neonatal conditions and
    describe the implications for care

3
What is a neonate?
  • An infant at any time during the first four
    weeks of life
  • (Oxford Concise Colour Medical Dictionary 1998)

4
The healthy baby
  • What colour?
  • What shape?
  • Skin?
  • Posture?
  • Activity?

5
What observations / measurements do we commonly
use to assess whether or not a baby is healthy?
6
  • Appearance and behaviour
  • Feeding (vomiting)
  • Urine and stools
  • Weight and centile charts
  • Normal baselines of physiological parameters e.g.
    heart rate, respiratory rate, blood pressure,
    temperature
  • Recommended measurement criteria such as presence
    or absence of reflexes, milestones etc
  • Gestational assessment scores e.g. Dubowitz

7
Basic needs (all infants)
  • Infant must maintain adequate
  • Respirations
  • Temperature
  • Nutritional intake, blood glucose
  • and weight gain
  • Keep infant PINK, WARM and SWEET

8
Basic needs
  • Protection from infection
  • Safety and security
  • Rest, sleep, appropriate interaction / play

9
Family
  • Roles
  • Attachment
  • Mother
  • fatigue
  • Physical discomfort
  • Communication
  • Previous experience

10
Definitions
  • Preterm
  • Baby born before 37 completed weeks of pregnancy
  • Term
  • Baby born between 37 completed weeks of
    pregnancy and before 42 completed weeks of
    pregnancy
  • Post Term
  • Baby born at or beyond 42 completed weeks of
    pregnancy

11
Definitions
  • Small for gestational age
  • Any infant whose weight is below the
  • 10th centile for his / her gestational age

12
Why is breathing more challenging for neonates,
especially if preterm?
13
Respiratory system
  • Babies are nose breathers
  • They mainly use the diaphragm muscle
  • Their respiratory rate is 40 60 bpm
  • They have small airways, short neck, large tongue
  • Some structures are floppy and can be noisy or
    cause obstruction
  • The respiratory centre is underdeveloped

14
Signs of respiratory distress
  • Tachypnoea
  • Nasal flaring
  • Grunting respirations
  • Sternal and intercostal recession
  • Cyanosis
  • Apnoea

15
Cyanosis
16
Cardiovascular system
  • Total blood volume 85 ml / kg
  • Heart rate 100 149 bpm
  • Hb 16 20 g/dl
  • More HbF than HbA allowing greater uptake of
    oxygen jaundice is more common
  • Heart as glycogen stores and designed to
    withstand labour / stress
  • May have congenital heart disease

17
Why is the infant vulnerable to temperature
instability?
  • Large surface area in relation to body volume
  • Inability to shiver
  • Immature hypothalamus

18
Surface area of the neonate vs. adult
19
Response to cold
  • Thermal nerve endings (receptors) in the skin
    detect that the skin temperature has fallen
  • This information is received and processed by the
    hypothalamus (functioning as a thermostat)
  • This results in a series of reactions to increase
    heat production and decrease heat loss

20
Processes involved in heat conservation
  • Voluntary skeletal muscle activity
  • Neonate may become restless and agitated when
    chilled thereby increasing muscle activity to
    generate heat
  • Infant may curl up in a flexed position to reduce
    exposed surface area

21
Processes involved in heat conservation
  • Involuntary muscle activity
  • Shivering generates heat in children and adults.
    However the neonate has limited ability to shiver
  • Peripheral vasoconstriction diverts the blood
    supply from the skin surface

22
Non-shivering thermogenesis
  • Brown fat is required which can rapidly mobilise
    heat resources i.e. free fatty acids and glycerol
  • Brown fat is richly supplied with blood vessels
    and nerves
  • Found at 26-28 weeks and continues to develop
    until 3-5 weeks postnatally
  • Process is dependant on oxygen, ATP and glucose
    (why are preterm, SGA vulnerable?)

23
Distribution of brown fat
24
Metabolism
  • High metabolic rate
  • High O2, energy need for increased metabolism
  • Glycogen stores easily exhausted
  • Prone to and less tolerant of hypoglycaemia
  • Low levels of liver enzymes for detoxification
  • At risk of drug toxicity

25
Hypoglycaemia
  • Normal blood glucose 2.6 mmol/l or above
  • Symptoms?
  • Significance?
  • Which infants are at risk and why?

26
Energy triangle
  • Temperature
  • Oxygen Blood glucose

27
Consequences of fall in temperature
  • Energy is required to generate heat
  • Glucose and oxygen are needed to produce energy
  • Energy production is much less efficient if
    hypoxic (anaerobic respiration)
  • Glucose and glycogen stores may become rapidly
    depleted leading to hypoglycaemia
  • Acidosis occurs as a result of hypoxia and
    vasoconstriction

28
PHYSIOLOGIC CONSEQUENCES OF COLD
STRESS(Blackburn S.T. (2003) Maternal, Fetal
Neonatal Physiology A Clinical Perspective.
St. Louis. Saunders. p.725)
29
Thermoneutral environment
  • Metabolic rate and hence oxygen consumption are
    at a minimum while the infant or child maintains
    a normal body temperature
  • An infant who is using a lot of energy to keep
    warm will gain less weight than if nursed in a
    thermoneutral environment

30
Fluid Balance
  • A person is in a state of water balance when
    daily gains and losses are equal
  • What gains and losses occur in a healthy baby?

31
Water gains and losses
  • Intake
  • Drinking
  • (Water in food)
  • Water of metabolism
  • Output
  • Urine
  • Respiration
  • Skin
  • Faeces

32
Estimating fluid needs
  • During the first few days following birth fluid
    requirements are based on insensible water loss
    and urine water loss
  • Fluid needs are higher in infants below 1000g
  • Infants with acute renal failure or congestive
    heart failure will need less fluid

33
How much?
  • DAY Less than 1kg
  • 1 90ml/kg/day
  • 2 120ml/kg/day
  • 3 150ml/kg/day
  • 180ml/kg/day
  • 180ml/kg/day
  • DAY More than 1kg
  • 60ml/kg/day
  • 90ml/kg/day
  • 120ml/kg/day
  • 150ml/kg/day
  • 180ml/kg/day

start at 90ml/kg/day and adjust according to
clinical condition and biochemistry. May need up
to 200ml/kg or more within 24 hours of birth
maximum for term babies
34
Functional and anatomical limitations
  • Because GI function is still maturing at birth
    especially in preterm newborn, there is increased
    risk of malabsorption and malnutrition
  • Maturation includes suck-swallow reflexes,
    oesophageal motility, function of cardiac
    sphincter, gastric emptying, intestinal motility,
    and development of absorptive surface area

35
Sucking and swallowing
  • Swallow reflex is well developed by 28-30 weeks
    gestation but is easily exhausted
  • This reflex is complete by about 34 weeks
  • All components of sucking and swallowing are
    present by 28 weeks, but the infant is unable to
    coordinate these activities
  • Some suck-swallow synchrony is seen 32-34 weeks
  • Synchrony complete by 36-38 weeks

36
Sucking, swallowing in preterm
  • Preterm, tend to have short bursts of sucking
    followed by swallowing, often accompanied by a
    rest period (for breathing) before sucking
    resumes
  • Preterm limited in ability to suck due to
    weaker flexor control (firm lip and jaw closure)
    and immature musculature

37
How do you assess that the infant is feeding
adequately?
  • Observation during feeds
  • General alert for feeds, skin turgor, anterior
    fontanelle, moist mucous membranes, wet nappies,
    stools
  • Weight gain
  • What about vomiting?

38
Immune system differences
  • Infections are more common than at any other
    stage in life
  • Reduced ability to react to infection due to
    reduced phagocytosis, low levels of
    immunoglobulins etc
  • Limited passive immunity from mother
  • Thin, easily broken skin allowing bacterial entry
  • More portals of entry for bacteria cord, eyes
    (no tears)

39
How does infection present in the neonate?
40
Nervous system
  • Brain makes up 12 of the total weight (in adults
    2)
  • System is immature even at birth
  • Low pain threshold
  • Infants need more sleep, particularly REM sleep,
    which is important for their brain development
  • Brain requires adequate stores of glucose and
    oxygen to function
  • Is vulnerable to biochemical instability, sepsis
    and haemorrhage
  • Neonates can see, hear and smell at birth

41
Migration of neurons
42
Dendritic growth
43
Urinary System
  • Urate crystals may colour urine red
  • Increased renal vascular resistance
  • Low glomerular filtration rate
  • Low ability to concentrate urine
  • Low ability to excrete acids or solutes
  • Low capacity for drug / toxic waste excretion
  • Poor response to excessive fluid overload

44
Which infants particularly require close
observation? (Why?)
  • Preterm
  • Small for gestational age
  • Infant of gestational diabetic mother
  • Poor feeding
  • Jaundice
  • Risk of infection
  • Maternal substance use
  • Neonatal abstinence syndrome
  • Fetal alcohol syndrome

45
References
  • Boxwell G. (Ed) (2010) Neonatal Intensive Care
    Nursing. 2nd Edition. London. Routledge.
    online
  • Blackburn S.T. (2013) Maternal, Fetal and
    Neonatal Physiology A Clinical Perspective. 4th
    Edition. Maryland Heights, Mo. Elsevier
    Saunders.
  • Bredemeyer S, Reid S, Wallace M. (2005) Thermal
    management for preterm births. Journal of
    Advanced Nursing. 52 (5) 482-4
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