PEDIA LECTURE
HIGH RISK NEWBORN
Problems related to:
1) Maturity
2) Birthweight
Intended Learning Outcome
At the end of this session, the students will
be able to:
1) Distinguish problems related to maturity
and gestational weight
2) Apply appropriate nursing concepts and
actions to a high-risk infant
3) Apply ethical reasoning and decision-
making processes to address situations of
ethical distress and moral dilemmas.
Overview of Perinatal and Neonatal
Mortality in the Philippines
Neonatal - a newborn infant or is a child
less than 28 days of age.
Perinatal - pertaining to the period
immediately before and after birth
Neonatal/InfantMortality Rate -
17.968/1,000 live births (2022)
18.392/1,000 live births (2021)
Neonatal Mortality Rate is highest during
the first 24 hours of life and overall accounts
for 65% of all infant deaths (deaths before 1
year of age)
Premature - liveborn infants delivered
before 37 weeks from the 1st day of the last
mentrual period
Low bithweight - birthweight of 2,500 g or
less
Premature - liveborn infants delivered
before 37 weeks from the 1st day of the last
mentrual period
Low birthweight - birthweight of 2,500 g or
less is due to prematurity, poor intrauterine
growth also called SGA or both
Very Low birthweight - birthweight less
than 1,500 gram
Extremely Low birthweight - birthweight
less than 1,000 gram
Age of Viability- 24 weeks of gestation
Characteristics
 Posture - hypotonic, partially flexed
(frog like posture) - assume
extended posture due to poor
muscle tone
 Skin - thin, gelatinous, shiny and
excessive pink with abundant lanugo
 Very littel vernix edema may be
present
 Breast nodules are small or absent
(<5mm)
 Subcutaenous fat is deficient
 Deep sole creases are often not
present in preterm baby
 HEMATOLOGIC
-Anemia (early or late onset)
-Hyperbilirubinemia-indirect
-Subcutaneous, organ (liver, adrenal)
hemorrhage
-Disseminated intravascular coagulopathy
-Vitamin K deficiency.
-Hydrops-immune or nonimmune

GASTROINTESTINAL
-Poor gastrointestinal function-poor motility
-Necrotizing enterocolitis.
-Hyperbilirubinemia-direct and indirect
-Congenital anomalies producing
polyhydramnios.
-Spontaneous gastrointestinal isolated
perforation

METABOLIC-ENDOCRINE
-Hypocalcemia
-Hypoglycemia
-Hyperglycemia
-Late metabolic acidosis
-Hypothermia
-Euthyroid but low-thyroxin status

CENTRAL NERVOUS SYSTEM

-Intraventricular hemorrhage
-Periventricular leukomalacia
-Hypoxic-ischemic encephalopathy
Neonatal Problems Associated with Premature -Seizures
Infants -Retinopathy of prematurity
-Deafness
-Hypotonia
RESPIRATORY
-Congenital malformations
-respiratory distress syndrome (hyaline
-Kernicterus (bilirubin encephalopathy)
membrane disease)
-Drug (narcotic) withdrawal
-Bronchopulmonary dysplasia
-Pneumothorax, pneumomediastinum;
RENAL
interstitial emphysema Congenital pneumonia
-Hyponatremia
-Pulmonary hypoplasia
-Hypernatremia
-Pulmonary hemorrhage
-Hyperkalemia
-Apnea
-Renal tubular acidosis
-Renal glycosuria
CARDIOVASCULAR
-Edema
-Patent ductus arteriosus
-Hypotension
OTHER
-Hypertension
Infections (congenital, perinatal, nosocomial:
-Bradycardia (with apnea)
bacterial, viral, fungal, protozoal)
-Congenital malformations

Intrauterine Growth Retardation

  Fetal growth restriction (FGR) - is said to
be present in those babies whose birth
weight is below the 10th percentile of
the average for the gestational age.
 It can occur in preterm, term or post
term babies.
 Intrauterine growth restriction - it is a
clinical definition and SGA is a statistical
definition.
Prognosis
In most cases, infants with IUGR ultimately have
good outcomes, with a reported mortality rate
of only 0,2 to 1 percent. These infants often
exhibit fast catch-up growth in the first three
months of life and attaining normal growth
curves by one year of age.

Clinical Features of IUGR baby Journal review.

 All SGA babies are IUGR but all IUGR • Intrauterine Growth Restriction: Antenatal
babies are not SGA
and Postnatal Aspects
 Loose skin folds in buttocks region
 Decrease subcutaneous fat
 Peeling of skin • Deepak Sharma, Sweta Shastri, and Pradeep
 Small abdomen Sharma
 Thin umbilical cord Published by:- PUBMED, 2016
 Old man like appearance Abstract

Factors Often Associated with Intrauterine  Intrauterine growth restriction (IUGR), a

Growth Restriction condition that occurs due to various
reasons, is an important cause of fetal
FETAL and neonatal morbidity and mortality. It
-Chromosomal disorders (e.g., autosomal has been defined as a rate of fetal
trisomies) growth that is less than normal in light
-Chronic fetal infections (e.g., cytomegalic of the growth potential of that specific
inclusion disease, congenital rubella, syphilis) infant.
-Congenital anomalies-syndrome complexes
 Usually, IUGR and small for gestational
Irradiation
age (SGA) are used interchangeably in
-Multiple gestation
literature, even though there exist
-Pancreatic hypoplasia minute differences between them. SGA
-Insulin deficiency has been defined as having birth weight
-Insulin-like growth factor type I deficiency less than two standard deviations below
the mean or less than the 10th
PLACENTAL percentile of a population-specific birth
weight for specific gestational age.
-Decreased placental weight or cellularity, or
both
 These infants have many acute neonatal
-Decrease in surface area problems that include perinatal
-Villous placentitis (bacterial, viral, parasitic) asphyxia, hypothermia, hypoglycemia,
-Infarction and polycythemia. The likely long-term
-Tumor (chorioangioma, hydatidiform mole) complications that are prone to develop
-Placental separation when IUGR infants grow up includes
-Twin transfusion syndrome growth retardation, major and subtle
neurodevelopmental handicaps, and
MATERNAL
developmental origin of health and
-Toxemia disease. In this review, we have covered
-Hypertension or renal disease, or both various antenatal and postnatal aspects
-Hypoxemia (high altitude, cyanotic cardiac or of IUGR.
pulmonary disease)
-Malnutrition or chronic illness
-Sickle cell anemia
Nursing Management for Premature Babies
-Drugs (narcotics, alcohol, cigarettes, cocaine,
antimetabolites)
Protect the airway
 Suction mouth and nostril after delivery
of the infant.
 Keep airway open.
Respiratory Support
 Administer oxygen therapy as needed.
 Monitoring respiratory rate and effort
 Providing assistance with mechanical
ventilation if required
 Ensuring proper positioning to optimize
respiratory function.
Temperature Regulation:
 Placing premature infants in incubators
or warmers to maintain a stable body
temperature.
 Monitoring temperature regularly to
prevent hypothermia.
Feeding Support
 Breast feeding is of the at most
importance, not only for the proper
nourishment but also for the protection
against infection which provides for the
low-birth-weight baby.
 Initiating and monitoring enteral
feeding through a tube if the baby is
unable to suck effectively.
 Gradually introduce oral feedings as the
baby’s sucking and swallowing abilities
improve.
 Monitoring for signs of feeding
intolerance or complications.
Infection Prevention
 Implementing strict hygiene protocols
to prevent infections.
 Administering antibiotics as prescribed
 Monitoring for signs of infection, such
as changes in vital signs or appearance
Cardiorespiratory Monitoring
 Continuous monitoring of heart rate,
respiratory rate, and oxygen saturation
 Prompt intervention in case of apnea or
bradycardia events.
Neurologic Monitoring
 Regular assessment of neurologic
status, including responsiveness and
reflexes
 Monitoring for signs of intraventricular
hemorrhage (IVH) or other neurologic
complications
Cardiorespiratory Monitoring
 Continuous monitoring of heart rate,
respiratory rate, and oxygen saturation
 Prompt intervention in case of apnea or
bradycardia events.
Developmental Support
 Providing a quiet and low-stimulation
environment to minimize stress.
 Encourage skin-to-skin contact between
baby and parents to promote bonding
and emotional well-being.
Parenteral Involvement and Education
 Educating parents about their baby’s
condition and care needs
 Encouraging parental involvement in
care activities, when appropriate
 Providing emotional support to parents
during what can be a challenging time.
Follow-up Care
 Coordinating follow-up appointments
and care after discharge
 Monitoring growth and development
milestones
 Providing resources and support for
parents to navigate the challenges of
caring for premature infants at home.
Collaboration with Multidisciplinary Team
 Working closely with neonatologists,
pediatricians, respiratory therapists,
dietitians, and other healthcare
professionals to ensure comprehensive
care.
Post-Term Infants (Postmature babies)
 Born after 42 weeks of gestation, as
calculated from the mother LMP,
regardless of weight at birth
 When delivery is delayed 3 weeks or
more before term, mortality
significantly increases three times
that of a control group of infants
born at term
 Average incidence is about 3-12%
(10%)
 Many suspected post-term
pregnancies/post-term births are
wrongly dated
 The case is unknown. Factors
associated with post-maturity include
anencephaly and trisomy 16-18.
Characteristics of post-term infants

 Decrease the amount of tissue

mass, particularly subcutaneous fat
 The skin may hang loosely on the
extremities and is often dry and
peeling
 The fingernails and toenails are long
and lanugo is present
 The nails and umbilical cord may be Other Problems in GDM
stained with meconium
 More alert and wide-eyed 1. Hypoglycemia, hypocalcemia
 Meconium aspiration syndrome is 2. Increased incidence of births
manifested by fetal hypoxia defects-TGA
 Respiratory distress may develop at 3. RDS
delivery 4. Hyperbilirubinemia
5. Polycythemia
Nursing Management of Post-Term infant 6. Birth trauma
1. Manage meconium aspiration
syndrome.
 Suction the infant's mouth and nares CASE 1
while the head is on the perineum
A baby girl at 39 weeks AOG was delivered
and before the first breath is taken to
via normal spontaneous delivery with a BW
prevent aspiration of meconium that
of 3kg and BL of 50cm. Can you give me
is in the airway.
the apgar score of this patient?
 Once the infant is dry on the
warmer, intubate (if needed)Perform With your APGAR Score assessment, what
chest physiotherapy with suctioning should immediate care be provided for that
to remove excess meconium and patient?
secretions
 Provide supplemental oxygen and CASE 2
respiratory support as needed
A baby boy 32 weeks AOG was delivered
2. Obtain serial blood glucose
via normal spontaneous delivery with a BW
measurement
of 1.8kg and BL of 45cm. APGAR score
3. Provide early feeding to prevent
was 5 and 7. Plot the weight of gestation.
hypoglycemia, if not contraindicated
by respiratory status. Wat is your initial nursing management of
4. Maintain skin integrity the patient? Give your answer
 Keep skin clear and dry chronologically.
 Avoid the use of powders, creams,
and lotions CASE 3

Large Gestation Age A baby boy at 40 weeks AOG was delivered

via cessarian section with a BW of 3.33kg
Birthweight >90th percentile for their and BL of 53cm. What is the APGAR score?
gestational age
What is the Ballard score?
Birthweight >2SD from mean weight for
gestation