At-Risk Newborn

Twila Brown, PhD, RN

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

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

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

Congenital Anomalies: Diaphragmatic Hernia Interventions

Oxygen Respiratory support without over

inflating Gastric decompression Head of bed elevated Turn to affected side ECMO Surgical repair

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

Congenital Anomalies: Tracheo-Esophageal Fistula Interventions

Withhold feedings Elevate head of bed Suction to blind pouch to decrease

aspiration Surgery

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

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

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

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

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

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

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

Substance-abusing Mother:

Fetal Alcohol Syndrome Facial abnormalities Behaviors

Difficulty establishing respirations Sleeplessness - Jittery Hyperalert states - Hyper

reflexes Inconsolable crying - Poor sucking Irritability - Lethargy

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

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

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

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

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

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

Identification of At-Risk Newborns

Gestational age Preterm Post-term

Size of neonate Small for gestational age Large for gestational age

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

Large for Gestational Age Complications

Birth trauma – ceohalopelvic disproportion

Asphyxia Meconium aspiration Polycythemia Hypoglycemia

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

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 < 40 mg/dl

Feeding IV fluid of 10% dextrose water

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

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

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

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

Post-term Infant Physical characteristics

Loose skin Decreased subcutaneous fat

Problems Hypothermia Hypoglycemia Asphyxia Meconium aspiration Polycythemia

Interventions Supportive

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

Premature Infant Problems

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

Apnea & Bradycardia Bradycardia: heart rate less than 100 bpm Apnea: not breathing for > 15 to20

seconds Causes of apnea

Obstructed airway Hypothermia or hyperthermia Hypoglycemia Sepsis Respiratory distress

Apnea and Bradycardia Causes of apnea

Anemia Hypercapnea Sepsis Hypocalcemia Seizure Vagal response Dehydration CNS depression Intraventricular hemorrhage

Apnea and Bradycardia Interventions

Tactile stimulation Suction airway Provide oxygen Provide mechanical ventilation Correct underlying cause Administer CNS stimulants

Caffeine or theophylline

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

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

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

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

Retinopathy of Prematurity

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

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

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

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

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

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

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 & women’s 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 A’s in maternal-neonatal nursing. (2004). Philadelphia: Lippincott Williams & Wilkins.