Paediatric Nursing I

Name of Facilitator:

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THE HIGH-RISK NEONATE AND THEIR CARE

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Who is a high-risk neonate?

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An infant who is susceptible to illness (morbidity) or even death
(mortality) because of immaturity, physical disorders, or
complications of birth.

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 DANGER SIGNS IN A NEWBORN
▪ Failure to pass meconium and urine
▪ Respiratory problems
▪ Thermal imbalances
▪ Cyanosis
▪ Pathological jaundice
▪ Lethargy/poor feeding
▪ Prolonged Capillary Refill Time
▪ Tracheo-esophageal fistula
▪ Congenital heart disease
▪ Vomiting
▪ Diarrhea
▪ Excessive weight loss CBP
 PREDISPOSING FACTORS
• Low socio-economic level

• Exposure to environmental dangers such as toxic chemicals

• Preexisting maternal conditions eg heart diseases and diabetes

• Obstetric factors, eg maternal age, parity

• Medical conditions related to pregnancy eg. maternal infections

• Obstetric complications eg abruptio placentae

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• Even though it is not always possible for nurses to
identify all high-risk newborns, they can anticipate
and prepare for their birth through adequate
prenatal care if they are aware of some of these
perinatal factors.

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• The pregnancy can be closely monitored

• Treatment can be instituted as necessary

• Arrangements can be made for birth to occur at a

facility with appropriate equipment and personnel
to care for mother and child.

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 ASSESSMENT OF NEWBORN

A thorough and rapid assessment of the newborn is done at

birth.

• This is to determine any problems and identify those that

demand immediate attention.

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The assessment includes:
▪Assignment of an Apgar score
▪An evaluation for any obvious congenital
anomalies
▪Evidence of neonatal distress

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APGAR score
It is the most useful and frequently used method to
assess the newborn’s immediate adjustment to
extrauterine life and identify the at-risk new born.

It reflects the general condition of the neonate at 1 and

5 minutes based on five parameters.

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The total score is achieved by assessing five
parameters. These are:
▪Color (Appearance)
▪Heart rate (Pulse)
▪Reflex irritability (Grimace)
▪Muscle tone (Activity)
▪Respiratory effort (Respiration)

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▪Each item is assigned a score of 0, 1 or 2.

▪Evaluation of all five categories are made

at 1 and 5 minutes after birth.

▪They are repeated until the infant’s

condition stabilizes.
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 SIGN 0 1 2

Heart rate Absent Slow (Less than More than 100

100)
Respiratory Absent Irregular, slow, Good, strong cry
effort weak cry

Muscle tone Limp Some flexion of Well flexed

extremities
Reflex No response Grimace Cry, sneeze
Irritability
Color Blue, pale Body pink,
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Total score at 5 minutes
0-3 (Low): Severe distress

4-6 (Intermediate): Moderate difficulty

7-10 (Normal): Absence of difficulty in
adjusting to extrauterine life

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•The lower the Apgar score at 5 minutes after
birth, the higher the incidence of neurologic
abnormalities at age 1 year.

•Research has shown that there is a higher

mortality rate for infants with an Apgar score
of 3 or less at 15 minutes of birth

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In addition to low Apgar score, other factors
influence the outcome of at-risk infants.
They include:
▪Birth weight
▪Gestational age,
▪Type and length of neonatal illness
▪Environmental
▪Maternal factors CBP
Classification of high risk INFANTS
The newborn classification and neonatal mortality
risk chart.

1. ACCORDING TO SIZE (BIRTH WEIGHT)

Neurologic abnormalities increase as birth weight
decreases.

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▪Low-birth-weight infant: Weight less than
2500g
▪Very-low-birth-weight infant: Birth weight of
less than 1500g
▪Extremely-low-birth-weight infant: Weight of
less than 1000g
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▪Small-for-date/gestational age infant:
➢A slowed down intrauterine growth and birth
weight of below the 10th percentile.

➢A small-for-gestational age infant could be

preterm, term or post-term

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 COMMON COMPLICATIONS OF SGA
▪Perinatal asphyxia
▪Aspiration syndrome
▪Heat loss
▪Hypoglycemia
▪Hypocalcemia
▪Polycythemia

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▪Intra-Uterine Growth Restriction (IUGR):
Found in infants whose intrauterine growth is
restricted.
•IUGR may not be apparent antenatally.
•Intrauterine growth is linear in the normal
pregnancy from approx. 28 to 38 weeks
gestation.
•Growth is variable after 38 weeks, depending on
the growth potential of the fetus and placental
function.
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Factors contributing to IUGR
IUGR may be caused by maternal, environmental, placental
or fetal factors.

MATERNAL
▪Malnutrition esp. during the last trimester
▪Vascular complications e.g PIH (Pre-eclampsia &
eclampsia), advanced DM cause diminished blood flow to
the fetus
▪Maternal disease eg SCD, Phenylketonuria (PKU)
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Other maternal factors:
Small stature, primiparity, grand multiparity,
smoking, alcohol, use of drugs such as
anticonvulsants, anti-metabolics, trimethadione
which may have teratogenic effects, lack of prenatal
care, age (< 16 or > 40), low socio-economic status.

Environmental
▪High altitude
▪X-rays
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Placental conditions such as;
▪Infarcted areas
▪Abnormal cord insertions
▪Single umbilical artery
▪Placenta previa
▪ Thrombosis
These may affect circulation to the fetus, which
becomes more deficient with increasing age.

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Fetal factors
▪ Congenital infections eg. Rubella
▪ Syphilis
▪ Toxoplasmosis
▪ Multiple pregnancy (twin or triplets)
▪ Sex of the fetus (Female)
▪ Chromosomal syndromes

All these can predispose a fetus to IUGR.

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▪Large-for-gestational-age infant: An infant whose birth
weight falls above the 90th percentile on intrauterine growth
charts.

NB

Majority of LGA newborns have been incorrectly

categorized because of miscalculation of the date of
conception.
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The cause of the majority of cases of LGA infants is
unclear.

The best-known condition is maternal diabetes.

Certain factors have been found to be associated with

their births.

▪Genetic predisposition: Large parents tend to have

large infants.
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▪Primigravida women

▪Male infants: Naturally larger than female infants.

▪Hemolytic disease of the newborn: Eg.
erythroblastosis fetalis, ABO incompatibility, Rh
incompatibility
▪Infant with neonatal sepsis

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COMMON COMPLICATIONS OF THE LGA
NEWBORN
▪Birth trauma because of CPD can result in:
➢Shoulder dystocias
➢Fractured clavicles
➢Brachial plexus palsy
➢Facial paralysis
➢Depressed skull fractures
➢Hematomas
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▪Increased incidence of caesarean births and
oxytocin induced births due to fetal size.

▪Hypoglycemia

▪Polycythemia

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2. ACCORDING TO GESTATIONAL AGE

THE PRETERM INFANT

▪The American Academy of Paediatrics defines a
preterm infant as one born before 37 weeks’
gestation.

▪Incidence in the US ranges from 7% of white

newborns to 14%-15% of non-whites
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▪Untimely departure from the uterus may mean that
various organs and systems are not sufficiently
mature.

▪With the help of modern technology, some babies

under 500g and between 23 and 26 weeks’ gestation
are surviving.

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 Classification of preterm infants
Extremely preterm infants: Born between 23
and 28 weeks of gestation

Moderately preterm infants: Born between 29

and 33 weeks of gestation

Late preterm infants: Born between 34 and 37

weeks of gestation
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 WHO CAN DELIVER A PRETERM BABY?
▪Any pregnant woman can deliver a preterm infant which
may happen without any warning signs.

▪The best predictor for who can deliver a preterm baby is a

woman who has previously given birth to a preterm baby.

▪Family history of preterm births.

▪Multiple births
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Women with uterine or cervical abnormalities (eg. Fibroids, uterine
septum)

OTHER RISK FACTORS

▪ Medical factors
-Infections: UTIs, STDs
-Diabetes
- Placenta related- praevia, abruptio
-High blood pressure
-Clotting disorders
-Bleeding from the vagina
-Certain defects in the fetus
-Short spacing between births
-Overweight or underweight
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Placenta previa

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abruptio placentae

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▪ Lifestyle factors
-Late or no prenatal care
-Smoking in pregnancy
-Alcohol consumption
-Illicit drug use
-Domestic violence
-Lack of social support
-Stress
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Characteristics of the preterm infant
▪ Tiny
▪ Red
▪ Has thin extremities
▪ Little muscle or subcutaneous fat
▪ Disproportionately large head and abdomen
▪ Thin, translucent, wrinkled skin
▪ More visible abdominal and scalp veins
▪ Plentiful lanugo over the extremities, back and shoulder
▪ Pliable ears (soft with minimal cartilage)

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▪ Soft skull bones (with the tendency to flatten on the sides)
▪ Undescended testes in males
▪ Prominent labia and clitoris in females
▪ Few creases in the soles of the feet and the palms
▪ Absence of or weak newborn reflexes

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NURSING MANAGEMENT OF THE
PRETERM INFANT
Discuss the nursing management of the
preterm infant under the following:
•Maintaining respiration
•Maintaining temperature control
•Kangaroo care
•Maintaining nutritional balance
•Protection/preventing infection
•Skincare CBP
 Complications of prematurity
▪Respiratory distress
▪Apnoea
▪Intraventricular hemorrhage
▪Patent ductus arteriosis

Long term problems include:

▪Retinopathy of prematurity (ROP)
▪Bronchopulmonary dysplasia (BPD)
▪Hearing loss
▪Speech defects
▪Neurologic defects CBP
PARENTRAL NUTRITION,
PREMATURE BABIES AND
NEONATAL INFECTIONS

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 INTRODUCTION
• Parenteral nutrition is the intravenous infusion of nutrients necessary
for metabolic requirements and growth.

• Partial parenteral nutrition (PPN) supplies only part of daily nutritional

requirements, supplementing oral intake.

• Total parenteral nutrition (TPN) or Intravenous hyperalimentation

(IVH) supplies all daily nutritional requirements.

• TPN can be used in the hospital or at home.

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 INTRODUCTION cont.

• Examples of TPN are 10% to 50% dextrose in water plus a mixture of

amino acids and special additives.

• Earlier introduction and more aggressive advancement of TPN is shown

to be safe

and effective, even in the smallest and most immature infants

• Premature infants tolerate TPN from day 1 of post-natal life

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The goal of TPN

• It provides sufficient nutrients to prevent negative energy and nitrogen

balance.

• TPN supports normal growth rates.

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 Indications of TPN
1. Gastrointestinal tract abnormalities (tracheo-esophageal fistula.

2. Gastroschisis, malrotation with volvulus, etc.

3. Necrotizing enterocolitis (NEC)

4. Respiratory Distress syndrome

5. Extreme prematurity

6. Sepsis

7. Mal-absorption
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Contra-indication

• Metabolic acidosis

• Acute renal failure – oliguria, ↑urea, ↑creatinine

• Cholestatic jaundice

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 Components of TPN
Essential components of parenteral nutrition are:
1. fluids
2. protein/ amino acids
3. electrolytes
4. carbohydrate
5. itamins e.g B complex, C, D, K
6. lipids
7. trace minerals e.g Zinc, magnesium
• Goal is to provide at least 100-110 cal/kg/day. Example: 150
mls/kg/day of 12.5% dextrose, 2.5 g/kg/day of synthetic amino acids, and
3.0 g/kg/day of intravenous lipids.
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 Infrastructure
• Place :NICU, Children’s Unit
• Prepared by: trained Doctor, trained nurse
• Asepsis: person preparing should be fully scrubbed, using all new
disposables every day
• Delivery: syringe pump, infusion pump, High pressure infusion lines,
chamber drip set, 3 way connector
• Monitoring: Trained nurse to monitor lines and baby

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 ADMINISTRATION OF TPN

• TPN should be delivered where possible through central lines

• Peripheral lines only if TPN ≤ 3 days duration and dextrose

concentration ≤ 12.5%

• Peripheral lines usage should be limited so as to prevent phlebitis.

• Percutaneous central line: confirm position of catheter tip with X-ray

prior to use.
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 ADMINISTRATION OF TPN cont.
• Strict aseptic technique in preparation and administration of the TPN is
essential

• Avoid breakage of the central line through which the TPN is infused

• Compatible drugs may be administered if necessary.

• Heparin is added to all TPN solutions; omitted on specialist orders if

contraindicated

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 Monitoring

Before starting an infant on parenteral nutrition, Laboratory investigations

are required:

1. Full blood count /haematocrit

2. Renal profile

3. Liver function test, bilirubin

4. Random blood sugar/dextrostix

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While on TPN, monitoring required
(Laboratory)

• Full blood count, renal profile. Daily for 1 week, then 3 times a week

• Plasma calcium, magnesium, phosphate. Twice a week until stable,

then weekly

• Triglyceride levels, weekly

• Liver function test: If long term TPN (> 2 weeks duration)

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While on TPN, monitoring required

• Blood sugar / dextrostix, 4-6 hrly first 3 days, twice a day once stable.

• Daily weight

• Meticulous care of the catheter site and monitoring of infection.

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 COMPLICATIONS
• Mechanical: thrombosis, embolism, skin slough

• Infections: particularly staph epidermidis, candida

• Metabolic: hypoglycaemia,
hyperglycaemia, cholestasis

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 POINTS TO REMEMBER

• Strict asepsis

• 24-hr TPN prepared at a time

• Changing infusion sets daily (ideal)

• New amino acid, lipid bottles daily (ideal)

• Separate IV access for other drugs

• Serum Na, K on alternate days;

urea, creatinie, Calcium biweekly

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Acknowledgement
• Thank you to all Tutors who contributed to this work

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