HIGH RISK NEWBORN: ACQUIRED

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HIGH RISK NEWBORN ACQUIRED CONGENITAL
CONDITIONS

• Binnece J. Green MSN APNC

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Respiratory Complications

• Respiratory distress- one of most common problems
  of newborn
• Cause asphyxia before or during birth, disease
  of respiratory system or other conditions
• Asphyxia at birth may be a continuation of this
  from in-utero
• Asphyxia few gasping breaths, followed by apnea
• Stimulation with or without oxygen may restart
  breathing
• Neonatal resuscitation- may be indicated

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Risk Factors for Asphyxia

• Difficult birth
• Fetal blood loss
• Apneic episode unrelated to tactile stimulation
• Inadequate ventilation
• Prematurity
• Cardiac arrest

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Newborn with Respiratory Distress

• RDS (respiratory distress syndrome)
• Factors prematurity
• surfactant deficiency
• Causes hypoxia, respiratory acidosis
• metabolic acidosis

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Meconium Aspiration

• Presence of meconuim in amniotic fluid indicates
  an asphyxial insult to the fetus before or during
  labor.

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Meconium Aspiration

• Manifestations of MAS
• Mild to severe respiratory distress
• Barrel shaped chest from hyperinflation
• Management
• Suctioning as soon as head is delivered to
  prevent drawing meconium into air passages
• Laryngoscope inserted after birth to do deep
  suction ventilation

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Persistent Pulmonary Hypertension

• Right to left shunting of blood away from the
  lungs and through the fetal ductus arteriousus
  and patent foramen ovale.

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Jaundice

• Develops from the deposit of yellow pigment
• bilibrubin in lipid tissues causes
• hemolytic disease of the newborn
• erythroblastosis fetalis
• hydrops fetalis

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Hyperbilirubinemia

• Pathologic jaundice
• Appears in first 24 hours after birth
• Above 12mg/dl in FT 10-14mg/dl in preterm
• May lead to kenicterus
• Yellowish staining of brain- encephalopathy
• Can result in CP, hearing loss, or MR
• May begin at levelsgt20mg/dl
• Rh or ABO incompatibility infection or
  impairment of liver causes

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Jaundice

• Therapeutic management
• Jaundiced infants direct Coombs test to
  determine presence of antibodies against fetal
  blood
• Phototherapy can be by lights or fiberoptic
  blanket
• Bilirubin in skin absorbs light and changes into
  water-soluble products
• Can be excreted in bile urine

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• Side effects of phototherapy
• Frequent loose green stools from increased bile
  flow
• Bronzing or skin rash
• Exchange transfusions
• Used when phototherapy does not reduce
  dangerously high bilirubin levels
• Blood is removed from infant and replaced by
  donor blood
• Keep infant warm during phototherapy feed every
  3 hours keep eyes covered position frequently
  use only a diaper

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Infection

• Affects 1 to 4 in every 1000 live births
• Responsible for more than 30 of neonatal deaths
• Transmission
• Vertical passage through placenta or during
  labor
• Horizontal after birth from hospital staff or
  other contaminants

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• Sepsis neonatorum- occurs as a systemic infection
  of the blood stream
• NB susceptible immature immune system cannot
  localize infection as well also have fewer
  antibodies
• Common causes Group B strep, E. Coli
• Early sepsis- 1st 3 days after birth
• Follows prolonged rupture of membranes
• Late sepsis 3 days to 2 months postbirth
• Meningitis common

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Infections (continued)

• Treatment
• Broad spectrum antibiotic IV
• Oxygen or intubation
• Fluid balance monitor hourly outputs
• Signs of infection
• Temp instablity, resp problems,
• Feeding problems

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Infants of a Diabetic Mother

• May be small for gestational age from IUGR as
  result of vascular changes
• Macrosomia 1/3 of IDMs
• Has excess adipose tissue
• If mother is hyperglycemic, excess glucose
  transferred to fetus, but insulin is not
• Fetal pancreas increases insulin which also acts
  as growth hormone
• Higher incidence in Native Americans, African
  Americans,
• And Pacific Islanders

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Infant of Diabetic Mothers

• Infants at risk for birth injuries, congenital
  anomalies respiratory distress (insulin
  interferes with surfactant), hypoglycemia,
• Hypocalcemia, respiratory distress and
  hyperbilirubinemia.

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Diabetes (continued)

• Care of infants
• Screening after birth for hypoglycemia
• Monitor for jitteriness or tremors
• Feed infants immediately if becomes hypoglycemic
  (glucose lt40-45mg/dl)

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Infants of a Substance Abusing Mother

• Abuse during first 2 months can cause anomalies
• Abuse later may interfere with development or
  functioning of organs
• Drug exposed infants
• Neonatal abstinence syndrome from opiates
• Neurotoxicity from cocaine
• Fetal Alcohol Syndrome (FAS)
• Growth Deficiency
• Respiratory Distress
• Withdrawal

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Substance Abuse Continued

• Symptoms begin about 2-3 days after birth
• Infant is irritable, hyperactive muscle tone,
  tremors high pitched cry
• Appear hungry sucks but have poor suck
  swallow coordination
• Restless may have seizures
• Urine tested from infant
• IV fluids is not able to eat, gavage feedings,
  skin care for irritation diaper rash
• Social service referral

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Phenylketonuria

• PKU genetic disorder causes CNS damage from
  toxic levels of amino acid phenylalanine
• Mental retardation results if untreated
• Treat with low phenylalanine diet
• Screening should be done after 48 hrs if done
  before, repeat test. After first feeding
• Good control of diet normal growth development

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Premature Newborn

• An infant born before the completion of 37 weeks
  gestation
• Incidence is 8 in US 15 in socioeconomically
  deprived populations
• Higher incidence in single women and adolescents
• Major problem is the variable immaturity of
  different health systems. ie lungs, rds, patent
  ductus arteriosus

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Premature Newborn

• LBW(5 lb 8 oz) or VLBW (3lb 5oz) or less at birth
• Survival rate now at 85-90 for infants at 1250 g
  to 1500 g 20 for infants at 500-600 g.
• Rate of preterm birth is not decreasing
  extremely costly

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Premature Newborn

• Thermoregulation preterm baby has a high ration
  of body surface to weight, little fat and thinner
  skin, deceased ability to vasoconstrict.
• ASSESSMENT
• Continuous monitoring with a skin probe
  attached to radiant warmer
• Assess axillary temp q. 4 hrs- (36.5-37.5º)
• Poor feeding or poor muscle tone or infection may
  be related to inadequate temperature control

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Prematurity Continued

• Patent ductus arteriosus
• Apnea
• Intraventricular hemorrhage
• Long term complications, vision, auditory
• speech.

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Premature Newborn

• APPEARANCE
• Frail, undeveloped muscles, limp extremities
• Lie in an extended position
• Skin translucent since it lacks s/c fat
• Vernix lanugo may be abundant
• Plantar creases absent 32 wkslt
• Female-labia clitoris are large male-
  undescended testes smooth scrotum

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Premature Newborn

• BEHAVIOR OF PRETERM INFANT
• Little excess energy to maintain muscle tone
  flexion
• Easily exhausted from noise routine activities
• Feeble cries
• Easily chilled
• Coughing, yawning, hiccuping regurgitation are
  signs of overstimulation require quiet time

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Concerns re Premature Newborn

• RESPIRATION
• Absence of surfactant respiratory distress
• Lungs not fully matured
• Differentiate periodic breathing from apnea
• Apnea lasts longer than 15 seconds also note
  cyanosis bradycardia
• Monitor for retractions
• Grunting early sign of resp. distress

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Intervention

• Oxygen hood often used for infants able to
  breathe but need oxygen
• Ventilation when neededContinuous positive
  airway pressure via cannula or endotracheal tube
• Many infants go home with nasal cannula should
  be warmed humidified

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Concerns with Fluid and Electrolytes

• Preterm infants lose fluid very easily
• Radiant warmers increase insensible loss
• Rapid respiratory rate use of oxygen can
  increase fluid loss from lungs
• Kidneys have decreased ability to concentrate
  urine
• Kidneys are immature glomerular filtration rate
  is lower
• Inability to excrete drugs increases chance of
  reactions

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Nutritional Requirements

• Methods of feeding
• Bottle/ or pumped breast milk
• Breastfeeding
• Gavage Feeding
• Transpyloric feeding
• Total parenteral nutrition

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Concerns with Infection

• Incidence is 3-10x greater
• Many have episode of sepsis
• Do not receive immunoglobulin G from mother
  immune response is decreased
• INTERVENTION
• Handwashing a must !

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Concerns with Pain

• Pain stimuli are now recognized to cause
  physiologic behavioral changes
• Preterm infants may be more sensitive to pain
  than older infants
• Monitor for changes in heart rate, respirations,
  BP, intracranial pressure and decreased oxygen
  saturation
• Use pain rating scales
• Gentle touch, gentle voice approach

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Concerns with Bonding

• Promote parent/infant attachment Normal for
  parents to experience fear
• Encourage speaking to infant, holding, massage,
  tape voice. ASSESSMENT
• Preparation
• Allow parents to see touch infant at birth
  assists in a realistic idea of infants status
• Provide visits to NICU as soon as possible and
  prepare the parents for what to see involve
  them in care eventual discharge

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RESPIRATORY DISTRESS SYNDROME

• Insufficient surfactant alveoli collapse with
  each exhalation
• Lungs become stiff- retractions occur
  eventually atelectasis hypoxia take place
• Next pulmonary vasoconstriction decreased
  pulmonary blood flow pulmonary hypertension
  occurs a return to fetal circulation
• BPDchronic lung disease
• Infant remains dependent on oxygen
• Occurs from high levels of oxygen high positive
  pressure ventilation
• Inflammation, edema, loss of cilia thickening
  of walls of alveoli
• Rales, retractions, increased secretions,
  characteristic changes in lungs/x-ray

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Respiratory Concerns (cont.)

• Management of BPD
• Maternal steroids to reduce prematurity
• Minimal exposure to oxygen and pressure
  ventilation
• Treatment is supportive with gradual decreases in
  oxygenation, bronchodilators, diuretics
  antibiotics as needed
• Infants who survive first year have gradual
  improvement in lung function

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Gastrointestinal Concerns

• Danger of aspiration
• Difficulty in meeting high caloric needs, due to
  inability to handle formula, lactose,feeding
  intolerence.
• Necrotic lesions (NEC) develop in mucosa of
  intestines
• May result from asphyxia blood is diverted from
  GI tract to the brain, heart kidneys
• Ischemia makes mucosa more susceptible to
  invasion of bacteria
• Encourage breastfeeding Breastmilk has a
  preventative effect

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Neurologic Concerns

• Peri or Intraventricular hemmorrhage- results
  from rupture of fragile blood vessels around
  ventricles of brain
• Associated with hypoxic injury to the brain
• If severe may have developmental delays CP
• Manifestations are related to severity
• Lethargy, poor muscle tone, apnea, decreased
  reflexes, bulging fontanelle, seizures
• Monitor with ultrasound q. 1-2 weeks
• Developmental care, early intervention, speech,
  OT/PT

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Immunologic Concerns

• Infant is at greater risk for infection
• Underdeveloped cellular immune system
• Skin is thin, and easily excoriated

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Concerns with Vision

• Retinopathy of Prematurity- Occurs more often in
  infants weighing less than 1000 g.
• Damage to immature blood vessels in retina of eye
• Results from too much or not enough oxygen,
  acidosis, mechanical ventilation, sepis, shock
• More common in VLBW babies
• Screen every 4-6 weeks after birth to detect eye
  changes

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Concerns with Hypoglycemia

• Occurs when the blood glucose level is less than
  40mg/dl, possible complications include
• lethary
• jittery
• high pitched cry
• poor feeding, vomiting
• pale
• apnea or respiratory distress
• hypotonia, tremors, seizures

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Newborn with Polycythemia

• Blood volume increased
• Symptoms tachycardia, congestive heart failure,
  respiratory distress, hyperbilirubinemia,
  jittery, seizures

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Newborn exposed to AID/HIV

• Maternal to newborn transmission 20-30
• Transmission can be decreased to 65 in mothers
  taking AZT
• Outcomes parent should bond with baby,
• identify infections,
• seek and accept outside assistance
• when needed.

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Post Term Infants

• Born after 42 week- risk of placental
  insufficiency
• Fetal distress may occur during labor
• Respiratory support may be needed for meconium
  aspiration or asphyxia
• Monitor for FHR declerations during labor
• Common disorders associated hypoglycemia,
  meconium aspiration, polycythemia, congenital
  anomalies, seiqures, cold stress due to loss of
  fat.
• Provide warmth, frequent blood glucose, initate
  early feeding or intravenous glucose

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LGA Large for Gestational
Age

• Neonate whose birth weight is at or above the 90
• Careful gestational age assessment is essential
• Factors associated with LGA genetic
  predisposition, multiparous, male infants,
  infants with erythroblastosis or transposition of
  the great vessels, diabetic mother

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LGA (continued)

• Tend to be more difficult to arouse
• May have problems maintaining a quiet, alert
  state
• Feeding problems
• Disorders can include birth trauma due to
  cephalopelvic disproportion
• Increased incidence Cesarean births
• Hypoglycemia, polycythemia

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SGA Small for Gestational
Age

• Below the 10th percentile for weight at birth
• Symmetric involves entire body
• Asymmetric head larger than body
• Higher incidence of perinatal aspyxia,
  polycythemia, heat loss and hypoglycemia
• Caused by maternal, placental or fetal factors
• increased risk with maternal smoking
• Congenital malformations, intrauterine
  infections, continued growth difficulties and
  learning disabilities
• Feeding concerns without distress and fatigue
• Temperature hemosatasis

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Predictable Risk Factors

• Low socioeconomic level
• Limited access to health care, education
• Exposure to toxic chemicals and illicit drugs,
  smoking.
• Preexisting maternal conditions heart disease,
  diabetes, hypertention
• Maternal age, parity
• Medical conditions related to pregnancy

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Care of the Family

• The birth of a baby with a problem or disorder
  can be very traumatic event with the potential to
  disrupt bonding
• Encourage discussion of feeling
• Empathetic listener
• Refer to social services
• Involvement in babies care as much as possible.