Module 3: High-Risk Newborn

Common Classifications of High-Risk Infants

 Altered Gestational Age or Birth Weight
Term infants
- are those born after the beginning of week 38 and before week 42 of pregnancy
(calculated from the first day of the last menstrual period).
- 90% of all live births fall into this category
Preterm infants
- infants born before term (before the beginning of the 38th week of pregnancy)
regardless of their birth weight
Postterm Infants
- infants born after the end of week 41 of pregnancy

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 Altered Gestational Age or Birth Weight
Appropriate for Gestational Age (AGA) - are infants who fall between the 10th and 90th
percentiles of weight for their gestational age, whether they are preterm, term, or postterm
Small for Gestational Age (SGA) - infants who fall below the 10th percentile of weight for
their age
Large for Gestational Age (LGA) - those who fall above the 90th percentile in weight
Low–birth-weight (LBW) infant - one weighing less than 2,500 g at birth
Very-low-birth-weight (VLBW) infant - one weighing less than 1500 g at birth
Extremely-low-birth-weight (ELBW) infant - one weighing less than 1,000 g at birth

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 Altered Gestational Age or Birth Weight
PRETERM INFANT
- a live-born infant born before the end of week 37 of gestation.
- divided into:
• early preterm - born between 24 and 34 weeks
• late preterm - born between 34 and 37 weeks
- neonatal assessments such as:
• inspection for sole creases
• skull firmness
• ear cartilage
• neurologic development
• LMP
• sonographic estimation of age
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 Altered Gestational Age or Birth Weight
PRETERM INFANT
- occurs in approximately 11% of live births worldwide - US (highest rates)
- most preterm infants need intensive care from the moment of birth to give them their
best chance of survival without neurologic aftereffects because they are more prone
than others to hypoglycemia and intracranial hemorrhage
- lack of lung surfactant, because this does not form until about the 34th week of
pregnancy, makes them extremely vulnerable to respiratory distress syndrome
- Cause is rarely exactly known / “No one really knows what causes prematurity.”
- Preterm vs SGA

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 Contrasts Between Small-For-Gestational-Age and Preterm Infants
Characteristic SGA Infant Preterm Infant
Gestational age 24–44 wk <37 wk
Birth weight <10th percentile Normal for age
Congenital Strong possibility Possibility
malformations
Pulmonary problems Meconium aspiration, Respiratory distress
most pulmonary hemorrhage, syndrome
apt to occur pneumothorax
Hyperbilirubinemia Possibility Very strong possibility
Hypoglycemia Very strong possibility Possibility
Intracranial Strong possibility Possibility
hemorrhage 7
 Contrasts Between Small-For-Gestational-Age and Preterm Infants
Characteristic SGA Infant Preterm Infant
Apnea episodes Possibility Very strong possibility

Most likely because of

Small stomach capacity;
Feeding problems accompanying problem
immature sucking reflex
such as hypoglycemia

Weight gain in nursery Rapid Slow

Possibly always be <10th

Not likely to be restricted
Future restricted percentile because of poor
in growth because “catch-
growth organ development
up” growth occurs
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 Common Factors Associated With Preterm Birth
1. Low socioeconomic level 10. Closely spaced pregnancies
2. Poor nutritional status 11. Abnormalities of the mother’s reproductive system,
such as intrauterine septum
3. Lack of prenatal care
12. Infections (especially urinary tract infections)
4. Multiple pregnancy
13. Pregnancy complications, such as premature
5. Previous early birth
rupture of membranes or premature separation of the
6. Race (non-Whites have a higher placenta
incidence of prematurity than Whites)
14. Early induction of labor
7. Cigarette smoking
15. Elective cesarean birth
8. Age of the mother (highest incidence is
in mothers younger than age 20 years)
9. Order of birth (early birth is highest in
first pregnancies and in those beyond
the fourth pregnancy) 9
 Altered Gestational Age or Birth Weight
PRETERM INFANT
Assessment:
- head appears disproportionately large (≥3 cm greater than chest size).
- the skin is generally unusually ruddy because there is so little subcutaneous fat
beneath it, making veins easily noticeable a high degree of acrocyanosis may be
present.
- preterm (less than 28 weeks of gestation) the vernix will be lacking.
- lanugo is usually scant the same way in very low gestation infants but will be
extensive, covering the back, forearms, forehead, and sides of the face in late preterm
babies.
- both anterior and posterior fontanelles will be small
- there are few or no creases on the soles of the feet 10
 Altered Gestational Age or Birth Weight
PRETERM INFANT
Assessment:
- eyes appear small in relation to term infants
- difficult to elicit, a pupillary reaction is present
- preterm infant has varying degrees of myopia (nearsightedness)
- ears appear large in relation to the head
- reflexes such as sucking with coordinated swallowing and breathing will be absent if
an infant’s age is below 33 weeks; deep tendon reflexes such as the Achilles tendon
reflex will also be markedly diminished
- much less active than a mature infant and rarely cries. If the infant does cry, the cry is
weak and high pitched.
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 Altered Gestational Age or Birth Weight
Potential Complications
Anemia of Prematurity
- occurs from a combination of immaturity of the hematopoietic system combined with
the destruction of red blood cells because of low levels of vitamin E
- normochromic, normocytic anemia
- S/S: pale, lethargic, and anorectic
- blood drawing for electrolytes – fewest possible
- delaying cord clamping at birth to allow a little more blood from the placenta to enter
the infant may also help reduce the development of anemia

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 Altered Gestational Age or Birth Weight
Acute Bilirubin Encephalopathy (ABE)
- is the destruction of brain cells by invasion of indirect or unconjugated bilirubin
- results from the high concentration of indirect bilirubin that forms in the bloodstream
from an excessive breakdown of red blood cells at birth.
- Preterm infants are more prone to this condition than term infants - the acidosis that
occurs from poor respiratory exchange, brain cells appear to be more susceptible to
the effect of indirect bilirubin than usual
- Preterm infants also have less serum albumin available to bind indirect bilirubin and
inactivate its effect
- ABE may occur at lower levels in these infants than in term newborns
- phototherapy or exchange transfusion can be initiated to prevent excessively high
indirect bilirubin levels 16
 Altered Gestational Age or Birth Weight
Acute Bilirubin Encephalopathy (ABE)

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 Altered Gestational Age or Birth Weight
Persistent Patent Ductus Arteriosus
- preterm infants may lack surfactant, their
lungs are noncompliant
- it is more difficult to move blood from
the pulmonary artery into the lungs.
- this condition leads to pulmonary
artery hypertension, which then
interferes with closure of the ductus
arteriosus
- always administer intravenous
therapy cautiously to preterm infants
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 Altered Gestational Age or Birth Weight
Persistent Patent Ductus Arteriosus
- administer indomethacin or ibuprofen to cause closure of a patent ductus arteriosus,
making ventilation more efficient
- given cautiously to preterm infants because it has been associated with adverse
effects such as decreased renal function, decreased platelet count, and gastric
irritation
- carefully monitor urine output and observe for bleeding, especially at injection sites

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 Altered Gestational Age or Birth Weight
Periventricular / Intraventricular Hemorrhage
- Periventricular hemorrhage - bleeding into the tissue surrounding the ventricles
- Intraventricular hemorrhage - bleeding into the ventricles
- because of fragile capillaries and immature cerebral vascular development.
- Intraventricular hemorrhage occurs most often in VLBW infants and is classified as:
▪ Grade 1, bleeding in the periventricular germinal matrix regions or germinal matrix,
occurring in one ventricle
▪ Grade 2, bleeding within the lateral ventricle without dilation of the ventricle
▪ Grade 3, bleeding causing enlargement of the ventricles
▪ Grade 4, bleeding in the ventricles and intraparenchymal hemorrhage

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 Altered Gestational Age or Birth Weight
Other Potential Complications
▪ respiratory distress syndrome
▪ apnea
▪ retinopathy of prematurity
▪ necrotizing enterocolitis

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 Altered Gestational Age or Birth Weight
SMALL FOR GESTATIONAL AGE (SGA)
- also called microsomia
- birth weight is below the 10th percentile on an
intrauterine growth curve for that age.
- can be born:
▪ Preterm: before week 38 of gestation
▪ Term: between weeks 38 and 42
▪ Postterm: past 42 weeks
- experienced intrauterine growth restriction (IUGR)
or failed to grow at the expected rate in utero
- a woman’s nutrition plays a major role in fetal
growth 22
 Altered Gestational Age or Birth Weight
SMALL FOR GESTATIONAL AGE (SGA)
Causes:
- adolescents – eat only enough to meet their own nutritional and growth needs
- placental issue – most common
- either the placenta did not obtain sufficient nutrients from the uterine arteries or it
was inefficient at transporting nutrients to the fetus
- the placental supply of nutrients is adequate but an infant cannot use them because
of a chromosomal abnormality or intrauterine infection such as rubella or
toxoplasmosis.
- women with systemic diseases that decrease blood flow to the placenta, such as
severe diabetes mellitus or gestational hypertension
- women who smoke heavily or use opiates 23
 Altered Gestational Age or Birth Weight
SMALL FOR GESTATIONAL AGE (SGA)
Assessment:
- detected in utero when fundal height during pregnancy becomes progressively less
than expected
- a sonogram can then demonstrate the decreased size
- a biophysical profile including a nonstress test, placental grading, amniotic fluid amount
- poor placental function
Appearance:
▪ reduction in weight
▪ overall wasted appearance
▪ the infant may have poor skin turgor
▪ generally appears to have a large head because the rest of the body is so small. 24
 Altered Gestational Age or Birth Weight
SMALL FOR GESTATIONAL AGE (SGA)
Assessment:
Appearance:
▪ skull sutures may be widely separated
▪ hair may be dull and lusterless.
▪ have a small liver, which can cause difficulty regulating glucose, protein, and
bilirubin levels after birth.
▪ the abdomen may be sunken
▪ the umbilical cord often appears dry and may be stained yellow.
▪ better developed neurologic responses, sole creases, and ear cartilage than
expected for a baby of that weight.
▪ unusually alert and active. 25
 Altered Gestational Age or Birth Weight
SMALL FOR GESTATIONAL AGE (SGA)
Assessment:
Laboratory Findings:
- high hematocrit level
- an increase in the total number of red blood cells (polycythemia)
Complications:
- an immediate effect of polycythemia is to cause increased blood viscosity,
- as a consequence, acrocyanosis (blueness of the hands and feet) may be prolonged
and persistently more marked than usual
- if the polycythemia is extreme, vessels may actually become blocked and thrombus
formation can result
- if the hematocrit level is more than 65% to 70%, an exchange transfusion to dilute
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the
blood may be necessary.
 Altered Gestational Age or Birth Weight
SMALL FOR GESTATIONAL AGE (SGA)
Assessment:
Complications:
- a second problem of polycythemia is hyperbilirubinemia because so many extra red
blood cells break down and release bilirubin.
- hypoglycemia (decreased blood glucose, or a level below 45 mg/dl) because SGA
infants have decreased glycogen stores
- such infants may need intravenous glucose to sustain blood sugar until they are
able to suck vigorously enough to take sufficient oral feedings.
- Birth asphyxia - is a common problem for SGA infants, both because they have
underdeveloped chest muscles and because they are at risk for developing meconium
aspiration syndrome (MAS) 27
 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
- also termed macrosomia
- birth weight is above the 90th percentile on
an intrauterine growth chart for that
gestational age.
- appears deceptively healthy at birth because
of the weight but a gestational age
examination often reveals immature
development.

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 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
Causes:
- subjected to an overproduction of nutrients and growth hormone in utero.
- happens most often to infants of women who are obese or who have diabetes mellitus
- multiparous women may also have large babies because with each succeeding
pregnancy, babies tend to grow larger.
- Beckwith–Wiedemann Syndrome - a rare condition characterized by general body
overgrowth and congenital anomalies such as omphalocele, may also be a cause.

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 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
Assessment:
- woman’s uterus appears to be unusually large for the date of pregnancy.
- sonogram can confirm the suspicion
- a nonstress test to assess the placenta’s ability to sustain a large fetus during labor
may be prescribed
- lung maturity may be assessed by amniocentesis.
- may be first recognized during labor when the baby appears too large to descend
through the pelvic rim.
- if this happens, a cesarean birth may be necessary because shoulder dystocia
would halt vaginal birth at that point.
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 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
Assessment:
- at birth - may show immature reflexes and low scores on gestational age
examinations in relation to their size
- they may have extensive bruising or a birth injury such as a broken clavicle or Erb–
Duchenne paralysis from trauma to the cervical nerves if they were stressed in order
for the wide shoulders to be born vaginally
- because the head is large, it may have been exposed to more than the usual amount
of pressure during birth, causing a prominent caput succedaneum,
cephalohematoma, or molding.
- large but often immature, they require the same cautious care necessary for a
preterm infant 31
 Important Assessment Criteria for a Large-For-Gestational-Age Infant
Assessment Rationale
Assess skin color for ecchymosis, Bruising occurs with vaginal birth because of
jaundice, and erythema the large size; polycythemia causes ruddiness of
skin. Ecchymosis is important to document
because jaundice may occur from breakdown of
ecchymotic collections of blood.
Assess motion of upper extremities is Clavicle or cervical nerve injuries may occur
spontaneous and also occurs in response to a because of problem at birth of wider than usual
Moro reflex to detect if clavicle fracture shoulders.
(crepitus or swelling may then be palpated at
the fracture site) or Erb’s palsy caused by
edema of the cervical nerve plexus are present.
Assess asymmetry of the anterior chest or The cervical nerve may be stretched by birth of
unilateral lack of movement to detect wide shoulders.
diaphragmatic paralysis from edema of the 32
 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
Cardiovascular Dysfunction
- Polycythemia - may occur in an LGA fetus as the fetus attempts to fully oxygenate
more than the average amount of body tissue.
- observe LGA infants closely for signs of hyperbilirubinemia that may result from
absorption of blood from bruising and breakdown of the extra red blood cells created
by polycythemia.
- assess the infant’s heart rate - if cyanosis is present, it may be a sign of poor heart
function, but it could also be from transposition of the great vessels, a serious heart
anomaly associated with macrosomia

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 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
Hypoglycemia
- If the mother had diabetes that was poorly controlled (the cause of the large size),
the infant would have had an increased blood glucose level in utero to match the
mother’s glucose level
- this caused the infant to produce elevated levels of insulin.
- After birth: insulin levels will continue after 24 hours of life, possibly causing rebound
hypoglycemia.
- LGA infants require large amounts of nutritional stores to sustain their weight.

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 Altered Gestational Age or Birth Weight
LARGE FOR GESTATIONAL AGE (LGA)
▪ As a rule: an LGA infant needs to be fed immediately after birth (preferably by
breastfeeding) to prevent hypoglycemia.
▪ these infants may need supplemental formula feedings after breastfeeding to supply
enough fluid and glucose for the larger than normal size for the first 24 hours.
▪ Additional glucose may be offered intravenously.

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 Altered Gestational Age or Birth Weight
POSTTERM INFANT
- is one born after the 41st week of a pregnancy
- Infants who stay in utero past week 41 are at special risk because a placenta
appears to function effectively for only 40 weeks.
Postterm syndrome
- demonstrate many of the characteristics of the SGA infant:
▪ dry, cracked, almost leatherlike skin from lack of fluid
▪ an absence of vernix
▪ fingernails will have grown well beyond the end of the fingertips
▪ demonstrate an alertness much more like a 2-week-old baby than a newborn.
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 Altered Gestational Age or Birth Weight
POSTTERM INFANT
Assessment:
- sonogram - to measure the biparietal diameter of the fetus
- a nonstress test or complete biophysical profile - to establish whether the placenta is
still functioning adequately.
- a cesarean birth may be indicated if a nonstress test reveals that compromised
placental functioning is apt to occur during labor.
- at birth, the postterm baby is likely to have difficulty establishing respirations,
especially if meconium aspiration occurred
- Polycythemia may have developed - from decreased oxygenation in the final weeks
- elevated hematocrit - because polycythemia and dehydration have lowered the
circulating plasma level 38
 Altered Gestational Age or Birth Weight
POSTTERM INFANT
Assessment:
- hypoglycemia may develop in the first hours of life - because the fetus had to use
stores of glycogen for nourishment in the last weeks of intrauterine life.
- subcutaneous fat levels may also be low, having been used in utero.
- this loss of fat can make temperature regulation difficult, making it important to
prevent a postterm infant from becoming chilled at birth or during transport.

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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
- formerly termed hyaline membrane disease
- is most often seen in newborns born prematurely.
- 30% in LBW infants, 50% in VLBW premature infants
- Other causes of RDS include NB with:
▪ meconium aspiration syndrome

▪ sepsis
▪ a newborn who is slow to transition to extrauterine life
▪ pneumonia

- Cause: low level or absence of surfactant

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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Pathophysiology:
↓ with deficient surfactant, areas of hypoinflation begin to occur and pulmonary
resistance increases
↓ blood then shunts through the foramen ovale and the ductus arteriosus as it did
during fetal life
↓ the lungs become poorly perfused
↓ a a result, the production of surfactant decreases even further
↓ the poor oxygen exchange that results leads to tissue hypoxia, which causes the
release of lactic acid
↓ combined with the increasing carbon dioxide level resulting from the formation of the
hyaline membrane on the alveolar surface, leads to severe acidosis 41
 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Pathophysiology:
↓ acidosis causes vasoconstriction and decreased pulmonary perfusion from
vasoconstriction, which further limits surfactant production.
↓ with surfactant production almost lost, the ability to stop alveoli from collapsing with
each expiration becomes more and more difficult
↓ this vicious cycle continues until the oxygen–carbon dioxide exchange in the alveoli is
no longer adequate to sustain life without ventilator support.

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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Assessment: As distress increases, an infant may exhibit:
▪ Low body temperature ▪ Seesaw respirations (on inspiration, the

▪ Nasal flaring anterior chest wall retracts and the

▪ Sternal and subcostal retractions abdomen protrudes; on expiration, the
▪ Tachypnea (more than 60 breaths/min) sternum rises)
▪ Cyanotic mucous membranes ▪ Heart failure, evidenced by decreased
urine output and edema of the extremities
▪ Pale gray skin
▪ Periods of apnea
▪ Bradycardia
▪ Pneumothorax 43
 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Diagnosis:
1. Clinical signs of grunting, central cyanosis in room air, tachypnea, nasal flaring, and
retractions
2. Chest X-ray will reveal a diffuse pattern of radiopaque areas that look like ground
glass (haziness) in the lungs.
3. Blood gas studies will reveal respiratory acidosis.
4. A β-hemolytic, group B streptococcal infection may mimic RDS because this infection
is so severe in newborns that it stops surfactant production
- Cultures of blood, cerebrospinal fluid, and skin may be obtained, therefore, to rule out this
condition.
- An antibiotic (penicillin or ampicillin) and an aminoglycoside (gentamicin or kanamycin) may
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be
 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Therapeutic Management:
1. Surfactant Replacement
- RDS can be largely prevented by the administration of surfactant at birth for an
infant at risk because of LGA
- Immediately after birth, synthetic surfactant is administered into an endotracheal
tube by a syringe or catheter (lung lavage)
2. Oxygen Administration
- necessary to maintain correct Po2 and pH levels following surfactant
administration

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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Therapeutic Management:
2. Oxygen Administration
- may be administered in a variety of ways from a simple cannula or mask,
continuous positive airway pressure (CPAP), or assisted ventilation with positive
end-expiratory pressure (PEEP)
- the advantage of CPAP or PEEP is that this exerts pressure on the alveoli at the end of
expiration and helps keep alveoli from collapsing in addition to supplying oxygen
- High frequency, oscillatory, and jet ventilation are still other methods of introducing
oxygen to infants with noncompliant lungs.
- these systems maintain airway pressure and then intermittently “jet” or oscillate an
additional amount of air at a rapid rate (400 to 600 times per minute) to inflate alveoli.
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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Therapeutic Management:
3. Ventilation
▪ infant ventilators with a reversed I/E ratio (2:1) - are pressure cycled to control the
force with which air is delivered.
▪ Watch out for complications: pneumothorax, impaired cardiac output, possible risk
of increased intracranial and arterial pressure, hemorrhage
4. Additional Therapy:
▪ Administration of Nitric Oxide (potent vascular dilator) - causes pulmonary
vasodilation without decreasing systemic vascular tone. It combines with
hemoglobin in the intravascular space to form methemoglobin.
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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Therapeutic Management:
4. Additional Therapy:
▪ Extracorporeal Membrane Oxygenation (ECMO)
- was first developed as a means of oxygenating blood during cardiac surgery
- use has expanded to include the management of severe hypoxemia in
newborns with illnesses such as meconium aspiration, RDS, pneumonia, and
diaphragmatic hernia
- formerly used as a mainstay of therapy for RDS, it is now rarely needed
because surfactant lavage is so effective.

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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Therapeutic Management:
5. Supportive Care
- An infant with RDS must be kept warm because cooling increases acidosis in
newborns, and for the newborn with RDS, acidosis may increase to lethal levels.
Prevention:
▪ Dating a pregnancy by sonogram and by documenting if the level of lecithin in
surfactant obtained from amniotic fluid exceeds that of sphingomyelin by a 2:1 ratio
▪ Using a tocolytic agent such as magnesium sulfate can help prevent preterm birth for
a few days.
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 ILLNESSES THAT OCCUR IN NEWBORNS
RESPIRATORY DISTRESS SYNDROME
Prevention:
▪ two injections of a glucocorticosteroid (such as betamethasone) - may be possible to
prevent RDS in the newborn because steroids appear to quicken the formation of
lecithin.
▪ the administration is most effective when given between weeks 24 and 34 of
pregnancy.

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 ILLNESSES THAT OCCUR IN NEWBORNS
TRANSIENT TACHYPNEA OF THE NEWBORN
▪ at birth, a newborn may have a rapid rate of respirations (up to 80 bpm) when crying,
caused by retained lung fluid
▪ doesn’t slow as a result of a delayed absorption of alveolar fluid in the lungs.
▪ mild retractions and some nasal flaring may be noticed
▪ some infants will be prescribed a mild glucosteroid - to reduce respiratory tract
inflammation.
▪ occurs more often in infants who are born by cesarean birth, in infants whose mothers
received extensive fluid administration during labor, and in preterm infants
▪ usually has an onset at about two hours of life and can last approximately 36 hours
▪ the higher the respiratory rate at onset, the longer TTN lasts.
▪ Treatment is supportive and typically by 72 hours of life it resolves 51
 ILLNESSES THAT OCCUR IN NEWBORNS
MECONIUM ASPIRATION SYNDROME
▪ Meconium is present in the fetal bowel as early as 10 weeks of gestation.
▪ If hypoxia occurs, a vagus reflex is stimulated, resulting in relaxation of the rectal
sphincter - this releases meconium into the amniotic fluid
▪ Babies born breech may expel meconium into the amniotic fluid from pressure on the
buttocks
▪ appearance of the fluid at birth is green to greenish black from the staining
▪ occurs in approximately 10% to 20% of all births; in 2% to 4% of these births, infants
will aspirate enough meconium to cause meconium aspiration syndrome (MAS)
▪ an infant may aspirate meconium either in utero or with the first breath at birth
▪ Meconium can cause severe respiratory distress (tachypnea, retractions, and
grunting). 52
 ILLNESSES THAT OCCUR IN NEWBORNS
MECONIUM ASPIRATION SYNDROME
Assessment :
▪ Difficulty establishing respirations at birth
▪ Apgar score is apt to be low
▪ Tachypnea, retractions and cyanosis begin
▪ The infant should be placed on the warmer, and resuscitation should begin including
the initiation of positive pressure ventilation as necessary
▪ After the initiation of respirations
▪ tachypnea, coarse bronchial sounds may be heard on auscultation.
▪ continue to have retractions because the inflammation of bronchi tends to trap air
in the alveoli, limiting the entrance of oxygen.
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 ILLNESSES THAT OCCUR IN NEWBORNS
MECONIUM ASPIRATION SYNDROME
Assessment :
▪ This air trapping may also cause enlargement of the anteroposterior diameter of
the chest (barrel chest)
▪ Pulse oximetry or blood gases will reveal poor gas exchange evidenced by a
decreased PO2 and an increased PCO2
▪ A chest X-ray will show bilateral coarse infiltrates in the lungs, with spaces of
hyperaeration (a peculiar honeycomb effect).
▪ The diaphragm will be pushed downward by the overexpanded lungs.

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 ILLNESSES THAT OCCUR IN NEWBORNS
MECONIUM ASPIRATION SYNDROME
Therapeutic Management :
1. Amnioinfusion can be used to dilute the amount of meconium in the amniotic fluid.
2. May be scheduled for a cesarean birth.
3. After birth, infants may need to be treated with oxygen administration and assisted
ventilation
4. Antibiotic therapy may be prescribed to forestall the development of pneumonia as a
secondary problem
5. If lung compliance is poor, surfactant may be administered.
6. Chest physiotherapy with percussion and vibration
7. Administered nitric oxide or maintained on ECMO to ensure adequate oxygenation
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 ILLNESSES THAT OCCUR IN NEWBORNS
APNEA
▪ is a cessation in respirations lasting longer than 20 seconds
▪ sometimes accompanied by bradycardia and/or cyanosis.
▪ many preterm infants have periods of apnea as a result of fatigue or the immaturity of
their respiratory mechanisms.
▪ babies with secondary stresses, such as infection, hyperbilirubinemia, hypoglycemia,
or hypothermia, tend to have a high incidence of apnea

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 ILLNESSES THAT OCCUR IN NEWBORNS
APNEA
Therapeutic Management:
▪ Gently stimulating an infant or flicking the sole of the foot often causes the baby to
breathe again - almost as if the infant needed to be reminded to maintain this function.
▪ If an infant does not respond to these simple measures, positive-pressure ventilation
and resuscitative interventions may be necessary
▪ To help prevent episodes of apnea, maintain a neutral thermal environment and use
gentle handling to avoid excessive fatigue.
▪ Always suction gently and only when needed to minimize nasopharyngeal irritation,
which can cause bradycardia because of vagal stimulation
▪ Using indwelling nasogastric tubes rather than intermittent ones canalso reduce the
amount of vagal stimulation. 57
 ILLNESSES THAT OCCUR IN NEWBORNS
APNEA
Therapeutic Management:
▪ After feeding, observe an infant carefully - a full stomach can put pressure on the
diaphragm and can potentially compromise respirations.
▪ Careful burping also helps to reduce this effect.
▪ Never take rectal temperatures in infants prone to apnea because the resulting vagal
stimulation can reduce the heart rate (bradycardia).
▪ Caffeine, a methylxanthine, may be prescribed for apnea of prematurity to stimulate
breathing - the mechanism by which this medication reduces the incidence of apneic
episodes is unclear, but they appear to increase the infant’s sensitivity to carbon
dioxide, which stimulates respiratory function.
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 ILLNESSES THAT OCCUR IN NEWBORNS
APNEA
Therapeutic Management:
▪ Infants who have had an apneic episode severe enough to require resuscitation are at
a high risk for sudden infant death syndrome
▪ Such infants may be discharged home with a monitoring device to be used for the first
several months of life.

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 ILLNESSES THAT OCCUR IN NEWBORNS
SUDDEN INFANT DEATH SYNDROME (SIDS)
▪ is a sudden unexplained death in infancy.
▪ occur at a higher than usual rate in infants of adolescent mothers, infants of closely
spaced pregnancies, and underweight and preterm infants.
▪ Also prone to SIDS are: infants with Bronchopulmonary dysplasia (BPD), twins, Native
American infants, Alaskan Native infants, economically disadvantaged Black infants,
and infants of narcotic-dependent mothers.
▪ The peak age of incidence is 2 to 4 months of age

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 ILLNESSES THAT OCCUR IN NEWBORNS
SUDDEN INFANT DEATH SYNDROME (SIDS)
Other possible contributing factors include:
▪ Sleeping prone rather than supine
▪ Viral respiratory or botulism infection
▪ Exposure to secondary smoke
▪ Pulmonary edema
▪ Brainstem abnormalities
▪ Neurotransmitter deficiencies
▪ Heart rate abnormalities
▪ Distorted familial breathing patterns
▪ Decreased arousal responses
▪ Possible lack of surfactant in alveoli
▪ Sleeping in a room without moving air
currents (the infant rebreathes expired
carbon dioxide)
61
 ILLNESSES THAT OCCUR IN NEWBORNS
SUDDEN INFANT DEATH SYNDROME (SIDS)
▪ do not appear to make any sound as they die (laryngospasm)
▪ found with blood-flecked sputum or vomitus in their mouths or on the bedclothes - this
to occur as the result of death, not as its cause.
▪ an autopsy often reveals petechiae in the lungs and mild inflammation and congestion
in the respiratory tract.
▪ However, these symptoms are not severe enough to cause sudden death.
▪ It is clear these infants do not suffocate from bedclothes or choke from
overfeeding, underfeeding, or crying.

62
 ILLNESSES THAT OCCUR IN NEWBORNS
SUDDEN INFANT DEATH SYNDROME (SIDS)
Recommendations:
▪ AAP recommended to put newborns to sleep on their back - incidence of SIDS has
declined almost 50% to 60%
▪ use of a firm sleep surface
▪ Breastfeeding
▪ room sharing without bed sharing
▪ Routine immunizations
▪ consideration of using a pacifier
▪ avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and
illicit drugs
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 ILLNESSES THAT OCCUR IN NEWBORNS
APPARENT LIFE-THREATENING EVENT (ALTE)
▪ is characterized by a noticeable color change, some degree of apnea, and decreased
tone
▪ apnea monitoring may be prescribed

64
 ILLNESSES THAT OCCUR IN NEWBORNS
PERIVENTRICULAR LEUKOMALACIA
▪ is the result of ischemia of the white matter of the brain
▪ it is caused by an anoxic episode that interferes with circulation to a portion of the
brain.
▪ occurs most frequently in preterm infants who experience cerebral ischemia
▪ once the condition has occurred, there is no therapy
▪ infants may die of the original insult; they may be left with long-term effects such as
learning disabilities or cerebral palsy
▪ any action to reduce environmental stimuli or sudden shifts in cerebral blood flow,
such as avoiding rapid fluid infusions or reducing pain, is important for preventing PVL
and limiting this long-term effect of prematurity
65
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
▪ the term “hemolytic” is Latin for “destruction” (lysis) of red blood cells.
▪ certain degree of lysis of red blood cells in the newborn results from the destruction of
red blood cells by a normal physiologic process as the newborn breaks down excess
red blood cells formed in utero
▪ Hemolytic disease is present when there is excessive destruction of red blood cells,
which leads to elevated bilirubin levels (hyperbilirubinemia)
▪ often caused by an Rh incompatibility (in the past), ABO compatibility

66
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
Rh Incompatibility
▪ introduction of fetal blood (Rh+) to maternal cuirculation (Rh-) causes sensitization to
occur and the woman to begin to form antibodies against the specific antigen (most
commonly the D antigen).
▪ most form in the woman’s bloodstream in the first 72 hours after birth because there
is an active exchange of fetal–maternal blood as placental villi loosen and the
placenta is delivered.
▪ 2nd Pregnancy - there will be a high level of antibody already circulating in the
woman’s bloodstream. This will then act to destroy the fetal red blood cells beginning
early in the next pregnancy if the new fetus is Rh positive, leading to the fetus being
severely compromised by the end of that pregnancy. 67
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
Rh Incompatibility
▪ Rh incompatibility is not commonly seen today because if Rh-negative women receive
Rho immune globulin (RHIG or RhoGAM) (passive Rh antibodies) within 72 hours
after birth of an Rh-positive newborn, the process of antibody formation will be halted
and sensitization will not occur.

68
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
ABO Incompatibility
▪ the maternal blood type is O and the fetal blood type is either A or B type blood
▪ hemolysis can become a problem with a first pregnancy in which there is an ABO
incompatibility because the antibodies to A and B cell types are naturally occurring
antibodies or are present from birth in anyone whose red cells lack these antigens.
▪ An infant of an ABO incompatibility - is not born anemic (antibodies do not cross the
placenta)
▪ Hemolysis of the blood begins with birth, when blood and antibodies are exchanged
during the mixing of maternal and fetal blood as the placenta is loosened; destruction
may continue for as long as 2 weeks.
69
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
Assessment:
▪ Rh incompatibility of the newborn can be predicted by finding a rising anti-Rh titer or
a rising level of antibodies (indirect Coombs test) in a woman during pregnancy.
▪ It can be confirmed by detecting antibodies on the fetal erythrocytes in cord blood
(positive direct Coombs test) by percutaneous umbilical blood sampling or at birth.
▪ an infant may not appear pale at birth
▪ the liver and spleen may be enlarged from attempts to destroy damaged blood cells.
▪ extreme edema - the blood in the vascular circulation may be hypotonic to interstitial
fluid, causing fluid to shift from the lower to higher isotonic pressure by osmosis
▪ the severe anemia can result in heart
70
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
Assessment:
▪ Hydrops fetalis is a Greek term
that refers to a pathologic
accumulation of at least two or
more cavities with a collection of
fluid in the fetus.
▪ With birth, progressive jaundice,
usually occurring within the first 24
hours of life - indicating in both Rh
and ABO incompatibility that a
hemolytic process is occurring.
71
 ILLNESSES THAT OCCUR IN NEWBORNS
HEMOLYTIC DISEASE OF THE NEWBORN (HYPERBILIRUBINEMIA)
Therapeutic Management:
▪ initiation of early feeding (urge mothers
to breastfeed 8 to 10 times a day for the
first 2 days)
▪ use of phototherapy
▪ exchange transfusion
▪ therapy with erythropoietin to stimulate
red blood cell production is also
possible

72
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
β-hemolytic, Group B streptococcal (GBS) Infection
▪ cause by gram-positive β-hemolytic, group B streptococcal (GBS) organism
Assessment:
▪ Universal screening is recommended for pregnant women at 35 to 37 weeks of
gestation to see if they have GBS organisms in their vaginal secretions
▪ a newborn at risk, such as one born after prolonged rupture of membranes or if the
woman’s vaginal culture is positive for GBS, will be screened at birth for infection by a
specialized GBS blood culture
▪ early-onset or a late-onset illness.

73
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
β-hemolytic, Group B streptococcal (GBS) Infection
Assessment:
▪ early-onset:
▪ signs of pneumonia such as tachypnea, apnea, extreme paleness
▪ hypotension, or hypotonia become apparent within the first day of life
▪ decreased urine output can occur from the hypotension.
▪ without therapy, the disease progresses so rapidly, as many as 20% of infants
who contract the infection die within 24 hours of birth.
▪ late-onset type occurs at 2 to 4 weeks of age
▪ instead of pneumonia being the infection focus, meningitis tends to occur
▪ typical signs include lethargy, fever, loss of appetite, and bulging fontanelles from
increased intracranial pressure. 74
▪ neurologic consequences can occur in up to 50% of infants who survive.
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
β-hemolytic, Group B streptococcal (GBS) Infection
Therapeutic Management:
▪ signs of infection and blood screening test is positive - antibiotics such as penicillin,
cefazolin, clindamycin, or vancomycin are all effective against the GBS organism.
▪ immunization of all women of childbearing age against streptococcal B organisms
could decrease the incidence of newborns infected at birth.

75
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
OPHTHALMIA NEONATORUM
▪ is an eye infection that occurs at birth or during the first month of life
▪ most common causative organisms: Neisseria gonorrhoeae and Chlamydia
trachomatis
▪ contracted from vaginal secretions
Assessment :
▪ conjunctivae become fiery red and covered with thick pus.
▪ eyelids appear edematous.
▪ occurs on day 1 to day 4 of life (in any infant younger than 30 days of age)

76
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
OPHTHALMIA NEONATORUM
Prevention:
▪ The prophylactic instillation of erythromycin ointment into the eyes of newborns
prevents both gonococcal and chlamydial conjunctivitis.
Therapeutic Management:
▪ If conjunctivitis occurs, therapy is individualized depending on the organism cultured
from the exudate.
▪ If gonococci are identified, intravenous ceftriaxone (Rocephin) and penicillin are
effective drugs.
▪ If Chlamydia is identified, an ophthalmic solution of erythromycin is commonly used.
▪ Use standard and contact infection precautions when caring for this newborn
▪ sterile saline solution lavage to clear the copious discharge from the eyes may 77
be
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
HEPATITIS B VIRUS (HBV)
▪ can be transmitted to the newborn through contact with infected vaginal blood at birth
when the mother is positive for the virus (positive for the surface antigen of the
hepatitis B virus [HBsAg+]).
▪ a destructive illness with greater than 90% of infected infants becoming chronic
carriers of the virus as well as the risk of developing liver cancer later in life
▪ to reduce the possibility of HBsAg being spread to newborns in the future, parents are
asked if they would like their infant vaccinated against hepatitis B at birth
Therapeutic Management:
▪ Gentle suctioning is necessary to avoid trauma to the mucous membrane, which
could allow HBV invasion.
▪ administer serum hepatitis B immune globulin (HBIG) in addition to the 78HBV
vaccination.
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
GENERALIZED HERPESVIRUS INFECTION
▪ a herpes simplex virus type 2 (HSV-2) infection
▪ most prevalent among women with multiple sexual partners
▪ can be contracted by a fetus across the placenta if the mother has a
primary infection during pregnancy.
▪ 15% and 30% of women of childbearing age demonstrate antibodies to this
virus or have the potential to have active lesions during labor

79
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
GENERALIZED HERPESVIRUS INFECTION
Assessment:
▪ an infant may be born with vesicles covering the skin (if the infection was acquired
during pregnancy)
▪ severe neurologic damage may have occurred simultaneously with the development
of the lesions
▪ if infants don’t acquire the infection until birth, by day 4 to day 7 of life - they show a
loss of appetite, perhaps a low-grade fever, and lethargy
▪ Stomatitis (ulcers of the mouth) or a few vesicles on the skin appear
▪ Herpes vesicles always cluster, are pinpoint in size, and are surrounded by a
reddened base.
▪ after the vesicles appear, infants become extremely ill - they develop dyspnea, 80
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
GENERALIZED HERPESVIRUS INFECTION
Assessment:
▪ death may occur within hours or days.
▪ between 25% and 70% of newborns who survive generalized herpesvirus infections
have permanent central nervous system sequelae
▪ to confirm the diagnosis, cultures are obtained from representative vesicles as well as
from the nose, throat, anus, and umbilical cord.
▪ blood serum is analyzed for IgM antibodies

81
THE NEWBORN AT RISK BECAUSE OF A MATERNAL INFECTION
GENERALIZED HERPESVIRUS INFECTION
Therapeutic Management:
▪ Acyclovir (Zovirax) - an antiviral drug, inhibits viral DNA synthesis, is
effective in combating this overwhelming infection.
▪ prevention, however, is the newborn’s best protection.
▪ antenatal antiviral prophylaxis reduces viral shedding and recurrences at
birth and reduces the need for cesarean birth
▪ cesarean birth rather than vaginal birth to minimize the newborn’s
exposure (for women with active herpetic vulvar lesions)
▪ infants with an infection should be separated from other infants in a
nursery. 82
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
AN INFANT OF A WOMAN WHO HAS DIABETES MELLITUS
▪ Macrosomia - results from overstimulation of pituitary growth hormone and extra fat
deposits created by high levels of insulin during pregnancy.
▪ greater chance of having a congenital anomaly such as a cardiac - because
hyperglycemia is teratogenic to a rapidly growing fetus.
▪ have a cushingoid (i.e., fat and puffy) appearance.
▪ tend to be lethargic or limp in the first days of life (due to hyperglycemia)
▪ this infant’s large size is deceptive, however, because, like all LGA babies, they are
often immature.
▪ RDS occur at a higher rate – due to preterm birth or at trm but lecithin pathways may
not be mature
▪ “fragile giant” 83
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
AN INFANT OF A WOMAN WHO HAS DIABETES MELLITUS
Complications:
▪ A macrosomic infant has a greater chance of birth injury
▪ Immediately after birth, the infant tends to be hyperglycemic.
▪ development of severe hypoglycemia.
▪ Hyperbilirubinemia
▪ Hypocalcemia also frequently develops because parathyroid hormone levels are
lower in these infants due to hypomagnesemia from excessive renal losses of
magnesium.
▪ Although infants of women with diabetes are usually LGA, an infant born to a woman
with extensive blood vessel involvement may be SGA because of poor placental
perfusion. 84
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
AN INFANT OF A WOMAN WHO HAS DIABETES MELLITUS
Therapeutic Management:
▪ feed early – to avoid a serum glucose level from falling low
▪ it is important the infant not be given only a bolus of glucose; otherwise, rebound
hypoglycemia (accentuating the problem) can occur.
▪ some infants of women with diabetes have a smaller than usual left colon, apparently
another effect of intrauterine hyperglycemia, which can limit the amount of oral
feedings they can take in their first days of life.
▪ Signs of an inadequate colon include vomiting or abdominal distention after the
first few feedings.
▪ Careful monitoring for any vomiting and normal bowel movements can help
identify this condition. 85
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
INFANTS OF DRUG-DEPENDENT MOTHER
▪ infant may show withdrawal symptoms (neonatal abstinence syndrome) shortly
after birth; symptoms occur in 24 to 48 hours and last about 2 weeks
▪ These include such signs as:
▪ Irritability
▪ Disturbed sleep pattern
▪ Constant movement, possibly leading to abrasions on the elbows, knees, or nose
▪ Tremors
▪ Frequent sneezing
▪ Shrill, high-pitched cry
▪ Possible hyperreflexia and clonus (neuromuscular irritability)
▪ Convulsions
▪ Tachypnea (rapid respirations), possibly so severe that it leads to hyperventilation and alkalosis
▪ Vomiting and diarrhea, leading to large fluid losses and secondary dehydration 86
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
Therapeutic Management :
▪ once an infant has been identified as having been exposed to drugs in utero the
mother needs treatment for withdrawal symptoms and follow-up care as much as the
infant.
▪ evaluation is necessary to determine before discharge from the healthcare facility
whether an environment that allowed for drug abuse will be safe for an infant at home
▪ Infants also need long-term follow-up because long-term neurologic problems may
develop.
▪ unless a woman intends to remain drug free, she is usually advised not to breastfeed
to avoid passing narcotics in breast milk to the infant.
▪ specific therapy for an infant has to be individualized according to the nature and
severity of the signs
▪ morphine and methadone - most common medications
88
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
AN INFANT WITH FETAL ALCOHOL EXPOSURE
▪ alcohol crosses the placenta in the same concentration as is present in the maternal
bloodstream so may result in fetal alcohol exposure, or fetal alcohol spectrum
disorder
▪ appears in about 2 out of 1,000 newborns
▪ more difficult to document than recreational drug exposure because alcohol abuse
may be more difficult to document.
▪ all pregnant women are advised to avoid alcohol intake to prevent any teratogenic
effects on their newborn

89
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
AN INFANT WITH FETAL ALCOHOL EXPOSURE
▪ A newborn with fetal alcohol spectrum disorder has several possible problems at birth.
▪ Characteristics that mark the syndrome include:
- prenatal and postnatal growth restriction
- central nervous system involvement such as cognitive challenge, microcephaly,
and cerebral palsy
- a distinctive facial feature of a short palpebral fissure and thin upper lip.
▪ during the neonatal period, an infant may appear tremulous, fidgety, and irritable and
may demonstrate a weak sucking reflex.
▪ sleep disturbances are common - always awake or always asleep
▪ the most serious long-term effect is cognitive challenge.
▪ behavior problems such as hyperactivity may occur in school-age children. 90
THE NEWBORN AT RISK BECAUSE OF A MATERNAL ILLNESSES
AN INFANT WITH FETAL ALCOHOL EXPOSURE
▪ growth deficiencies may remain throughout life.
▪ an infant needs conscientious follow-up so any future problems can be discovered.
▪ the mother needs a follow-up to see if she can reduce her alcohol intake for better
overall health

91