High Risk Neonate

Outlines
• Classification of high risk neonates
• Intensive care facilities and organization of
services
• Nursing care of high risk neonates
• Preterm infant
• Postterm
• Respiratory distress syndrome
• Neonatal jaundice
• IDM
• Neonatal sepsis
 Objectives:
By the end of the lecture the students will be able to
1- Define high risk neonate accurately.
2- Identify the different classifications of the high risk
neonates.
3- Define prematurity and identify its causes.
3- Identify the major prematurity handicaps.
4- Discuss respiratory distress syndrome.
5- Explain Neonatal jaundice (hyperbilirubineamia).
6- identify signs, causes and treatment of neonatal
sepsis.
 High Risk Neonate-Definition

A newborn , regardless of gestational age or birth

weight , who has a greater than average chance of
morbidity or mortality because of conditions or
circumstances associated with birth and the
adjustment to extrauterine existence.

The high risk period is from the time of viability

(the gestational age at which the survival outside
the uterus is possible ,as early as23 weeks of
gestation) to 28 days after birth.
High Risk Neonate- Classification
Size Gestational age Mortality
LBW Preterm (premature) Live birth

VLBW Full-term infant Fetal death

ELBW Late-preterm infant Neonatal death

AGA Postterm (postmature)

infant Perinatal mortality

SGA

IUGR

LGA
 According to Size

Low Birth weight (LBW): Birth wt is less than 2500g regardless of

gestational age.
Very Low Birth weight (VLBW): Birth wt is less than 1500g
Extremely Low Birth weight (ELBW): Birth wt is less than 1000g.
Appropriate for Gestational Age (AGA): Birth wt falls between 10th
and 90th percentile on intrauterine growth curves.
Small for Gestational Age (SGA): Wt below the 10th percentile.
Intrauterine Growth Restriction (IUGR): Intrauterine growth is
retarded.
Large for Gestational Age (LGA): Birth wt is above the 90th
percentile on the intrauterine growth chart
Intrauterine Growth Curve
 According to Gestational Age
• Preterm: An infant born before completion
of 37 weeks of gestation regardless of birth
weight
• Late Preterm: An infant born between 34
and 36 weeks of gestation

• Full term: An infant born between the

beginning of the38 weeks and the
completion of the 42 weeks of gestation
regardless of birth weight

• Post term: An infant born after 42 weeks of

gestational age regardless of birth weight.
 According to Mortality
Live birth: Birth in which the neonate manifests any heartbeat,
breathes or displays voluntary movement regardless of
gestational age.

Fetal death: Death of the fetus after 20 weeks of gestation and

before delivery with absence of any signs of life after birth.

Neonatal death: Death that occurs in the first 27 days of life.

Perinatal mortality: Total number of fetal and early neonatal

deaths per 1000 live births.
Intensive care facilities and
organization of services
Incubator and Radiant Warmer
Characteristics of Preterm Infants

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Characteristics of Preterm Infants

• Small and appear skinny because of very

minimal or no subcutaneous fat
• Proportionately large head
Characteristics of Preterm Infants
Skin
• Bright pink, often translucent, depending on
the degree of maturity
• Smooth and shiny ( may be edematous)
• Small blood vessels clearly visible underneath
the thin epidermis
• Abundant fine lanugo hair .
• Sparse , fine and fuzzy hair on the head
 Characteristics of Preterm Infants
Posture - The preterm infant lies in a relaxed
attitude , limbs more extended

Full term baby preterm baby

 Characteristics of Preterm Infants

Ear - Ear Cartilages are poorly

developed and the ear may fold
easily

Sole - have fine wrinkles

 Characteristics of Preterm Infants
Male genitalia
• Scrotum is undeveloped and not pendulous
• Minimal rugae are present
Testes may be in the inguinal canal or in the
abdominal cavity
Female genitalia
• Clitoris is prominent .
• Labia majora are poorly developed and gaping
 Characteristics of Preterm Infants
Scarf sign - Elbow may be easily
brought across the chest with
little or no resistance

Heel –to- ear maneuver – heel is

easily brought to the ear, meeting
with no resistance.

Week or absent reflexes – sucking,

swallow, gag cough,grasp
Physiologic Challenges of Premature Infant

• Respiratory and Cardiac

• Thermoregulation
• Digestive
• Renal
• Infection
• Cranial molding
• Parent – Infant Attachment
Nursing care of the high risk newborn

• Systematic Assessment
• Monitoring physiologic data
• Safety measures
• Respiratory support
• Thermoregulation
• Protection from infection
• Hydration and Nutrition
• Skin care
• Administration of medications
• Facilitating parent-infant relationship
 Nursing care of the high risk newborn

• Thermoregulation (Heat Loss)

– Increased body surface area
– Decreased brown fat
– Thin Skin
– Lack of flexion
• Provide Neutral thermal environment
– Incubator or Radiant warmer
– Warm surfaces, Warm humidified oxygen,
Warm feedings
– Keep skin dry and head covered
Nursing care of the high risk newborn

• Digestive
– Small stomach capacity
– Relaxed cardiac sphincter
– Poor suck and swallow reflex
– Difficult fat, protein and lactose digestion
 Nursing care of the High Risk Newborn

Nutrition and Hydration – Nursing

Interventions
– Daily weights
– Monitor I&O
– Parenteral nutrition
– Accurate feedings, minimal enteral feeding
– Monitor urine pH and specific gravity
 Nursing care of the High Risk Newborn

• Pre-feeding assessment
– Measure abdominal girth
– Bowel sounds
– Gastric residual
– Sucking and gag reflexes
 Nursing care of the High Risk Newborn

Prevention of Infection – Nursing Interventions

– Initial scrub / strict hand washing
• Visitors & staff

– Reverse isolation
– Single infant equipment
– Maintain sterile technique
• IV start and dressing changes
• Procedures

– Clean incubators weekly

– Position changes
 Nursing care of the High Risk Newborn

• Facilitating Parent-Infant Attachment

• https://www.youtube.com/watch?v=8WEpV3a_6e4
– Prepare parents for first visit
– Establish safe/trusting environment
– Encourage visitation
– Involved in care taking
– Repeat explanations
– Promote touching, talking, rocking, cuddling
– Kangaroo care
– Refer to infant by name
– Allow parents to phone as desired
 Postterm infant

• Infant born after week 42, regardless of the

birth weight
• Causes: unknown
• Characteristics:
– absence of lanugo
– Little if any vernix caseosa
– Abundant scalp hair
– Long fingernails
– Cracked skin
 Postterm infant

• Thin appearance because of depletion of

subcutaneous fat
• Significate increase in fetal mortality of postterm
infants compared with full term infants
• Fetal distress because of decrease placental efficacy
and meconium aspiration syndrome
 RDS (Respiratory Distress Syndrome)

RDS (Hyaline membrane disease ) is primarily a

disease related to developmental delay in lung
maturation.
It is seen almost exclusively in preterm infants.
 Pathophysiology
It is combination of structural and functional immaturity of the lungs. Immaturity
of the surfactant system plays a central role
 Clinical manifestations:
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 Clinical manifestations:
Signs of RDS appear immediately after birth or within 4 h
• Tachypnea > 60 - 120 breaths/min)
• Dyspnea
• Retraction
(intercostal or substernal )
• Fine inspiratory crackles
• Audible expiratory grunt
• Nasal flaring
• Cyanosis or pallor
Clinical manifestations:
 Therapeutic management

Treatment outcomes are:

• Maintain adequate ventilation and oxygenation
• Maintain acid-base balance.
• Maintain a neutral thermal environment.
• Maintain adequate tissue perfusion and oxygenation.
• Prevent hypotension.
• Maintain adequate hydration and electrolyte status.
 Therapeutic management

Respiratory:

1. Antenatal glucocorticoids
2. Surfactant replacement therapy
3. Ventilatory assistance with oxygen therapy
 Antenatal glucocorticoids
• Accelerate fetal lung maturity by
increasing formation and release of
surfactant and maturing the lung
morphologically
• Administered at least 24 to 48 h (and
no more than 7 d) before preterm
delivery.
 Therapeutic management
2- Surfactant

• Administration of surfactant have shown

improvement in blood gas values, decrease
incidence of pulmonary air leaks and decrease
death from RDS.
• Administered via the ET tube directly into the
infant's trachea. Prophylactic or Rescue
administration
• The dose of surfactant is:
– Infasurf™ 3mL/kg
– Survanta™ 4 mL/kg
 Therapeutic management
3- Oxygen Therapy

Ventilatory assistance with oxygen therapy

to maintain PaO2 between 50-70 mmHg or O2
saturation (by pulse oximetry) between 85-92%
The goal of oxygen therapy is to
- provide adequate oxygen to the tissues
- prevent lactic acid accumulation
- potentially prevent the negative effects of oxygen
toxicity
Oxygen must be warm and humidified
before administration.
 Therapeutic management
2- Oxygen Therapy (Cont.,)

Methods of oxygen administration RDS

1. CPAP ( Nasal, ET, Face mask)
The application of 3-8 cm H2O positive pressure to the
airway, use the infant spontaneous respiration to
improve oxygenation by preventing atelectasis and
reduce pulmonary edema.

2. Mechanical ventilation
Intermittent Mandatory ventilation (IMV) with Positive end
respiratory pressure (PERP).this allow the infant to breath by
their own rate but provides positive pressure with end
expiratory pressure to overcome airway resistance

3. High Frequency Ventilation

(HFV): when PCO2
more than 55, PO2 less than 50 and severe apnea.
 Therapeutic management
3-Nitric oxide

• It is a colorless, highly diffusible gas that causes

smooth muscle relaxation and reduces pulmonary
vasoconstriction and hypertension
• Administration: blended with oxygen
 Therapeutic management
4. Medical therapies

• Optimizing fluids and nutrient management.

• Infection & temperature control.
• Sysemic antibiotics: infection
• Morphine:pain
• Caffeine: Apnea and to prepare for weaning from
mechanical ventilation
• Intropes such as Dopamine:to support the
systemic blood pressure and maintain effective
cardiac output
 Nursing care management

• Observe and assess the response to

therapy.
• Continuous monitoring and close
observation.
• Infection prevention care.
• Airway care and suctioning.
• Mouth care.
 Infant of Diabetic Mother(IDM)

• Infant survival is affected by the severity of maternal

diabetes.
• Effects of Diabetes on the fetus:
• Neonatal Hypoglycemia after birth due to increase
Insulin activity in the blood.
• LGA(big baby): due to fetal fat deposition that
resulted from stimulated fetal islet cells to control
maternal hyperglycemia.
• Delayed fetal lung maturation.
 Clinical manifestation

• Macrosomic for gestational age, very plump and

full faced, liberally covered with vernix caseosa
• Infants of mothers with advanced and
uncontrolled DM can suffer from Intra Uterine
Growth Retardation
(IUGR)
• More susceptible to hypoglycemia
hyperbilirubinemia .
• More susceptible to congenital anomalies.
• More susceptible to RDS.
Signs of Newborn Hypoglycemia

• Irritability • Cyanosis
• Jitteriness • Poor feeding
• Eye rolling • Hypotonia
• Seizures • Apnea
 Therapeutic management

• Careful monitoring of blood glucose level.

• Continuous observation for possible
complications such as RDS.
• IV administration of Glucose if
hypoglycemia occurs (less than 40mg/dl).
• Bolus of IV glucose if unable to feed
immediately
 Hyperbilirubinemia in newborns

• Hyperbilirubinemia is an excessive level

of accumulated bilirubin in the blood.
• It is characterized by jaundice which is
yellowish discoloration of the skin or
other organs.
• It may result from increased
unconjugated or conjugated bilirubin.
 Normal physiology
RBCs

hemoglo
bin
Hem Globi
e n
Unconjugate
d
Iron Bilirubin
Glucuronic Action of
acid liver
glucuronyl
Conjugated transferase
Bilirubin
GLUCURONI
DE

Excreted
through feces
or urine
Causes of hyperbilirubinemia
• Physiological (developmental) factors
(prematurity).
• Association with beast-feeding or breast milk.
• Excess production of bilirubin e.g (hemolytic
disease).
• Disturbed capacity of the liver to secrete
conjugated bilirubin e.g(bile duct obstruction)
• Combined overproduction and under excretion .
• some diseases such G6PD and hypothyroidism.
• Genetic predisposition to increase production
 Physiologic jaundice

Mechanism involved in physiologic jaundice:

Newborn production as twice bilirubin as adults

do because of high concentration of
erythrocytes and a shorter life span (70-90
days)

Liver ability to conjugate bilirubin is reduced

due to limited production of glucuronyl
transferase.

Lower plasma binding capacity to bilirubin due

to lower albumin concentration.
 Physiologic jaundice

Normally , conjugated bilirubin is reduced to

urobilinogen by the intestinal flora and
execrated in feces.

In neonates, the sterile and less mobile

intestine is less effective in execration.
Jaundice in breast-feeding infants

1)Breast-feeding associated jaundice ( early-onset jaundice)

-Begins at 2-4 days of age and approximately 12%-13% of
breast-fed newborns experience it.
-It is related to the process of breast-feeding and decreased
caloric and fluids intake
2)Breast milk jaundice ( late-onset jaundice)
-Begins at age of 4-7 days and occurs in 2%-4% of breast-fed
newborns.
-It is caused by factors in the breast milk (fatty
acid,pregnanediol and β-glucuronidase) that either inhibits
the conjugation or decrease the excretion.
 Clinical manifestation

• The most obvious sigh of

hyperbilirubinemia is jaundice.

• It is primarily of the sclera, nails and the

skin.
 Diagnostic evaluation

The evaluation of jaundice is based on the serum

bilirubin plus the following:
• Timing of the appearance of clinical jaundice.
• Gestational age at birth
• Age since birth
• Family history including maternal conditions.
• Feeding method
• Evidence of hemolysis.
 Complications

• Unconjugated bilirubin is highly toxic , so a

newborn with jaundice is at risk for
bilirubin encephalopathy (Kernicterus ) is the
yellow staining of the brain cells that may result
in brain damage.
Signs of bilirubin encephalopathy:
• Prodormal symptoms consists of : decreased
activity, lethargy , irritability, and decrease
feeding.
• After several days: rigid extension of all 4 limbs,
fever, irritable cry, and seizures.
• Those who survives may show evidence of mental
delay ,ADHD, delayed motor development,
sensory alteration.
Therapeutic management

Phototherapy:
consists of
exposing the
infant's skin to
fluorescent light.
 Therapeutic management
• Light promotes bilirubin excretion by
photoisomerization , which alters the structure of
bilirubin to a soluble form (lumirubin) for easier
excretion.
• An infant must be fully exposed for the light to be
effective.
• The color of the infant's skin doesn’t influence the
efficacy of the phototherapy.
• Best results occurs within the first 24-48 hr of the
treatment.
 Therapeutic management

• Exchange transfusion if the bilirubin

is rapidly and critically increasing.
• Early recognition prevents
unnecessary medical therapy.
 Nursing care management
Phototherapy care:
Frequent (6-12 hr) serum bilirubin level.
Eyes and genitalia must be covered with
eye shield or pads to prevent light
exposure.
Temperature monitoring.
Adequate hydration and nutrition.
Oily lubricants or creams not to be used.
 Side effects of phototherapy
• Loose, greenish stool,
• skin rash, mild hyperthermia, increased metabolic rate
and dehydration.
• Rebound effect.
• Bronze-baby syndrome. An intense grey-brown
discoloration of the skin, serum, and urine, and anemia.
Pre-existing hepatic disease was suspected as a cause of
the joundice and may have prevented the biliary
excretion of the photooxidation products of bilirubin;
their retention resulted in the bronze discoloration
Neonatal sepsis
 Definition & Incidence
• Sepsis or septicemia refers to a generalized
bacterial infection in the bloodstream
• Incidence
– 1-8/1000 live births
– 13-27/1000 live births for infants < 1500g
• Mortality rate is 13-25%
– Higher rates in premature infants and those with
early fulminant disease
 Early Onset
• First 5-7 days of life
• Usually prominent respiratory symptoms (due
to aspiration of infected amniotic fluid)
• High mortality rate
– 5-20%
• Typically acquired during intrapartum period
from maternal genital tract
 Late Onset
• May occur as early as 5 days but is most
common after the first week of life
• Less association with obstetric complications
• Usually have an identifiable focus
– Most often meningitis
– Acquired from maternal genital tract or human
contact
 Nosocomial sepsis
• Occurs in high-risk newborns
• Pathogenesis is related to
– the underlying illness of the infant
– the flora in the NICU environment
• Breaks in the barrier function of the skin
 Causative organisms
• Primary sepsis
– Group B streptococcus
– Gram-negative enterics (esp. E. coli)
– Staphylococcus, other streptococci (entercocci),
anaerobes, H. flu
• Nosocomial sepsis
– Varies by nursery
– Staphylococcus epidermidis, Pseudomonas, Klebsiella,
Serratia, and Proteus, are most common
 Risk factors
• Prematurity and low birth weight
• Premature and prolonged rupture of membranes
• Maternal fever
• Amniotic fluid problems
• Resuscitation at birth, fetal distress
• Multiple gestation
• Invasive procedures
• Other factors: sex, race, variations in immune
function, hand washing in the NICU
 Clinical presentation
• Temperature irregularity (high or low)
• Change in behavior
• Lethargy, irritability, changes in tone
• Skin changes
• Poor perfusion, mottling, cyanosis, pallor,
petechiae, rashes, jaundice
• Feeding problems
• Intolerance, vomiting, diarrhea, abdominal
distension
• Cardiopulmonary
• Tachypnea, grunting, flaring, retractions,
apnea, tachycardia, hypotension
• Metabolic
• Hypo or hyperglycemia, metabolic acidosis
 Clinical presentation
• Clinical signs and symptoms are nonspecific
• Differential diagnosis
– RDS
– Metabolic disease
– Hematologic disease
– CNS disease
– Cardiac disease
– Other infectious processes (i.e. TORCH)
 Diagnosis
• Cultures
– Blood
• Confirms sepsis
• 94% grow by 48 hours of age
– Urine
• Don’t need in infants <24 hours old because UTIs are
exceedingly rare in this age group
– CSF
• Controversial
• May be useful in clinically ill newborns or those with positive
blood cultures
 Radiology
• CXR
– Obtain in infants with respiratory symptoms
• Renal ultrasound in infants with
accompanying UTI
 Management
• Antibiotics
– Primary sepsis: ampicillin and gentamicin
– Nosocomial sepsis: vancomycin and gentamicin or
cefotaxime
– Change based on culture sensitivities
 Supportive therapy
• Respiratory
• Oxygen and ventilation as necessary
• Cardiovascular
• Support blood pressure with volume expanders
and/or pressors
• Hematologic
• Treat DIC with FFP and/or cryo
• CNS
• Treat seizures with phenobarbital
• Watch for signs of SIADH (decreased UOP,
hyponatremia) and treat with fluid restriction
• Metabolic
• Treat hypoglycemia/hyperglycemia and
metabolic acidosis
 GBS Prophylaxis
• Group B strep infection (GBS) is the most
common cause of early-onset sepsis
– 0.8-5.5/1000 live births
– Fatality rate of 5-15%
• 10-30% of women are colonized in the vaginal
and rectal areas
• Most mothers are screened at 35-37 weeks
gestation
 Nursing care management
• Hand washing
• Knowledge about side effects of antibiotics
• Provide optimum thermoregulated environment
• Anticipate potential problems such as
dehydration or hypoxia
• Precautions are implemented to prevent the
spread of infection to other newborns
• Use of disposable equipment
• Disposal of excretions
Thank you