1

HIGH RISK NEWBORN

Maybelle Tipon-Beltran RN.,MD

Newborn Priorities in 1st days of Life:

1. Respiration
2. Circulation
3. Temperature
4. Nourishment
5. Elimination
6. Prevention of Infection
7. Infant-Parent Relationship
8. Developmental Care

I. Respiration
a. Most deaths during 48 hrs after birth
b. (+) Difficulty and survives  Neurologic dysfunction due to cerebral hypoxia
c. (+) Respiratory acidosis  Inadequate defense mechanisms
A. Resuscitation
a. Factors Predisposing Respiratory Difficulty
i. LBW
ii. Maternal DM
iii. PROM
iv. Maternal use of Barbiturates or Narcotics
v. Meconium staining
vi. Irregularities in fetal monitor
vii. Cord prolapse
viii. Low Apgar <7
ix. Post mature
x. SGA (Small for Gestational Age)
xi. Breech
xii. Multiple birth
xiii. Chest, heart or respiratory tract anomalies
b. Ineffective Breathing  (+) PDA  Increase left side heart pressure  L to R
shunting  Ineffective heart pumping
c. (+) Struggle  Decrease glucose quickly  Hypoglycemia
d. Process:
i. Establish and maintain AW
ii. Expand Lungs
iii. Initiate and maintain ventilation
e. (+) Respiratory depression  Heart fails
f. Include cardiac massage

B. Airway
a. Bulb syringe suction
b. (-) 1st breath  suction mouth and nose, rub the back
c. Prevent chilling
d. (+) Meconium stained: Do not stimulate
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i. Give O2 by mask without pressure
ii. Insert laryngoscope  suction  give O2 under pressure
e. Place head in neutral position
f. Slide a catheter (8F – 12F)
g. Do not suction >10 secs
h. (-) Spontaneous respiration  Laryngoscope  Deep tracheal suctioning  ET
tube  Give O2 by (+) pressure bag and mask with 100% O2 at 40-60 bpm
i. Primary apnea
j. Secondary apnea
k. Laryngoscopes and ET tube
l. Laryngoscope size: 0 – 1 (NB)
m. ET tube: <1000 g  2.5 mm, >3000 g  4.0 mm
n. Gentle care during insertion is crucial

C. Lung Expansion
a. (+) Crying  Lung expansion is good
b. Mask should cover mouth and nose  100%, 40-60 bpm
c. Warmed (32-34C) and humidified (60-80%)
d. Pressure to open lung alveoli: 40 cmH2O
e. 15-20 cmH2O  continuous inflation
f. Monitor with pulse oximeter
g. Auscultate
h. Insert OGT and leave distal end open

D. Drug Therapy
a. Naloxone (Narcan): Narcotic antagonist; injected into umbilical vessel or IM thigh;
i. 0.01 – 0.1 mg/kg/BW
b. Atropine: Decreases bronchial secretions, decreases vagus nerve effects
c. CaCl: Increases HR
d. Dopamine: Increases BP  Increases perfusion
e. Epinephrine:
i. Strengthens or initiates cardiac contractions
ii. Increases HR and BP
f. Lidocaine: Counteracts ventricular arrhythmias
g. NaHCO3: Corrects metabolic acidosis
h. Surfactant: Prevents RDS in <1,500 g
i. NO: Potent vasodilator

E. Ventilation Maintenance
a. ↑RR  1st sign of obstruction  undress the chest  look for retractions
b. Place under warmer
c. Elevate head 15 degrees
d. Suction secretions
e. “Bag” infant for 1 min before sunctioning
f. Monitor with pulse oximeter

II. Circulation
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a. (-) HR or HR <80 bpm  closed chest massage
b. 1 or 2 cm depth, 30x
c. Lung ventilation at 30x/min
d. Continue monitoring with pulse oximeter
e. (-) HR: Epinephrine 0.1 – 0.3 ml/kg (1: 10,000) thru ET tube
f. Transfer to high risk nursery
g. Fluid and Electrolyte Balance:
i. Hypoglycemia, dehydration
ii. LR or D5W + Electrolytes (Na or K+) and glucose
iii. (+) Warmer  requires more fluid
iv. Monitor UO and urine specific gravity
v. UO: <2ml/kg/hr or sp gravity >1.015-1.020  Dehydration
vi. ↓BP  Give Dopamine
vii. (+) Hypovolemia  NSS or LR
viii. Control rate to prevent heart failure, PDA or Intracranial hemorrhage

III. Temperature
a. Keep NB in neutral temperature with environment
b. (+) Chills  ↑metabolism  ↑O2 demand  hypoxic  vasoconstriction 
↓pulmonary perfusion  ↓pO2, ↑pCO2  open fetal R-L shunts  ↓Surfactant
c. Anaerobic glycolysis  acidosis  Kernicterus
d. Maintain axillary temperature at 36.5C
e. Radiant Heat Source:
i. Radiant Warmer
1. (+) Servocontrol probes  continually monitors temperature
2. abdominal skin temperature: (35.5 – 36.5C)  ↓  alarm
3. Tape the probe between umbilicus and xiphoid
4. Place plastic bridge or shield to preserve heat
ii. Incubators
1. (+) Servocontrol probes
2. Portholes must remain closed
3. (+) Improve  weaning until room temperature is reached
iii. Kangaroo Care
1. Skin to skin contact
2. Infant is undressed except diaper
3. parent child interaction

IV. Nutritional Intake

a. (+) Asphyxia, (-) NEC  IVF
b. ↑RR, (-) NEC  Gavage feeding
c. Preterm  breastfeed, or may use breast pump
d. Gavage fed infants needs oral stimulation

V. Waste Elimination
a. Document voiding: Proof that hyotension is improving
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VI. Preventing Infection
a. Prenatal: CMV and toxoplamosis  Congenital anomalies
b. Perinatal: Group B strep, Candida, Herpes
c. Postnatal: Health care personnel  NB

VII. Parent-Infant Bonding

a. Tour women to NICU
b. Inform parent about what is happening during resuscitation
c. Parents should be able to visit the special receiving unit
d. Urge parents to spend time with infant as infant improves
e. (+) Infant dies: Parents need to see the infant without being covered

VIII. Developmental Needs

a. Anticipatory guidance
i. Follow-up at home
1. Before discharge: Safety of home should be evaluated
2. Transporting: Blanket, head support
ii. High risk Infants and Child Abuse: Due to separation of child from family at
birth

ALTERED GESTATIONAL AGE OR BIRTH WEIGHT

 Term: 38 – 42 wks
 Preterm: <37 wks
 Postterm: >43 wks
 AGA: 10th and 90th percentile of weight regardless of gestational age
 SGA: Below 10th percentile of weight
 LBW: <2,500g
 Very LBW: 1000-1,500g
 Extremely very LBW: 500-1000g

1) SGA
a) Preterm, term, postterm
b) (+) IUGR or failed to grow at expected rate
c) Causes:
i) ↓Mother’s nutrition (Adolescents)
ii) Placental anomaly
(1) Developmental defect
(2) Placental damage
iii) Systemic disease (DM)
iv) Smokers or use of narcotics
v) Intrauterine infection
vi) Chromosomal abnormality
d) Assessment:
i) Perinatal assessment
(1) ↓FH than expected
(2) Ultrasound: small size
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(3) BPP: Poor placental perfusion CS
(a) NST
(b) Placental grading
(c) AF amount
(d) Ultrasound exam
ii) Appearance
(1) Small liver
(2) Poor skin turgor
(3) Large head
(4) Widely separated skull sutures
(5) Hair is dull and lusterless
(6) Sunken abdomen
(7) Cord appears dry and stained yellow
(8) Better developed neurological responses, sole creases, ear cartilage
(9) Skull may be firmer
(10) Alert and active
iii) Lab. Findings
(1) ↑hct  >65 – 70%  exchange transfusion
(2) ↑RBC  blood viscosity  acrocyanosis
(3) Hypoglycemia (<40 mg/dl)

 Nursing Diagnoses:
o Ineffective breathing pattern r/t underdeveloped body systems
 Resuscitation
 Observe RR and character
o Risk for Ineffective thermoregulation r/t lack of SC fat
 Control environment
o Risk for Impaired Parenting r/t Child’s High Risk Status and Possible Cognitive or
Neuro. Impairment from lack of Nutrition in Utero
 Discuss to parents ways to promote infants development
 Provide toys suitable for age

2) LGA (Macrosomia)
a) Causes:
i) Overproduction of GH in utero
ii) DM mothers
iii) Multiparous women
iv) Conditions associated with LGA
(1) Transposition of Great Vessels
(2) Beckwith syndrome
(3) Ompahocele
b) Assessment:
i) Uterus is unusually large for the date of pregnancy
ii) Sonogram  Confirm
iii) NST  assess placental perfusion
iv) Assess lung maturity by Amniocentesis
v) (-) Descent
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vi) CPD, Shoulder dystocia  CS
vii) Appearance:
(1) Immature reflexes
(2) Extensive bruising or birth injury
(a) Ecchymosis, jaundice, erythema
(b) Clavicle or cervical nerve injuries
(c) Asymmetry of anterior chest
(d) Unresponsive or dilated pupils
(e) Seizure
(3) Prominent caput succedaneum, cephalhematoma or Molding
(4) CV Dysfunction
(a) Polycythemia
(b) (+) Stress on the heart
(c) (+) Cyanosis  Transposition of Great Vessels
(5) Hypoglycemia
(a) ↓glucose to sustain the weight
(b) (+) DM mother  ↑glucose in utero  ↑insulin production  continues up to
24 hrs of life  Rebound hypoglycemia

 Nursing Diagnoses:
o Ineffective Breathing Pattern r/t Possible Birth trauma  CS
o Risk for Imbalanced Nutrition Less than body requirements r/t additional nutrition
needed to maintain weight and prevent hypoglycemia
 Breastfeed immediately
 Supplemental formula feedings
o Risk for Impaired Parenting r/t High risk status
 Needs the same developmental care
 Encourage parents to treat their baby as a fragile NB

3) Preterm
a) <37 wks AOG
b) Weight <2,500 g (5 lb 8 oz) at birth
c) Lack of surfactant
d) Difference between SGA and Preterm
i) Characteristics SGA Preterm
ii) Gestational age 22-44 wk <37 wks
iii) BW <10 th percentile Normal for
age
iv) Cong. Malformations Strong possibility Possibility
v) Pulmo. Problems Meconium aspiration, RDS
Hemorrhage, penumothorax
vi) Hyperbilirubinemia Possibility Very strong
vii) Hypoglycemia Very strong Possible
viii) IC hemorrhage strong possibility Possible
ix) Apnea episodes Possible Possible
x) Feeding problems Hypoglycemia Small stomach,
poor suck
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xi) Wt gain in nursery Rapid Slow
xii) Future restricted growth Possible under 10 percentile “Catch up
th

growth”
e) Incidence:
i) Watch for specific problem of prematurity
ii) RDS, hypoglycemia, Intracranial hemorrhage
f) Causes:
i) Low socio economic level ix) Order of birth
ii) Poor nutritional status x) Closely spaced pregnancies
iii) Lack of prenatal care xi) Abnormalities of the mother’s
iv) Multiple pregnancy reproductive system
v) Previous early birth xii) Infections
vi) Race xiii) OB complications
vii) Cigarette smoking xiv) Early induction of labor
viii) Age of the mother xv) Elective CS
g) Assessment:
i) History:
(1) Pregnancy history
(2) Do not convey disapproval of reported pregnancy behaviors
ii) Appearance:
(1) Appears small and underdeveloped
(2) Head is disproportionately large (3 cm or > chest)
(3) Skin is unusually ruddy
(4) Veins are easily noticeable
(5) Acrocyanosis
(6) Covered with vernix caseosa
(7) Lanugo is usually extensive
(8) Few or no creases on soles of feet
(9) Eyes are small
(10) Myopia
(11) Immature ear cartilage, pinna falls forward
(12) Ears appears large in relation to head
(13) <33 weeks:
(a) (-) Sucking and swallowing reflex
(b) (-) Achilles tendon reflex
(14) Less active, rarely cries
(15) (+) Cry; weak and high pitched
iii) Laboratory Findings:
iv) Potential Complications:
(1) Anemia
(a) Normochromic, normocytic anemia
(b) ↓Reticulocyte count
(c) Pale,lethargic and anorectic
(d) Keep a record of the amount of blood drawn
(e) Give DNA recombinant erythropoietin
(f) BT, Vit. E and iron
(2) Kernicterus
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(a) Acidosis
(b) ↓albumin  ↓bind to indirect bilirubin
(c) (+) Jaundice  phototherapy or exchange transfusion
(3) Persistent PDA
(a) ↓surfactant  ↓blood from pulmonary artery to lungs  Pulmonary artery HPN
 PDA
(b) Hydrate
(c) Give Indomethacin or Ibuprofen
(i) Complication of Indomethacin: Oliguria  monitor UO closely
(4) Periventricular/ Intraventricular Bleeding
(a) (+) Fragile capillaries and immature cerebral vascular development
(b) (+) Rapid change in cerebral BP  capillaries rupture
(i) Hypoxia
(ii) IV infusion
(iii) Ventilator
(iv)Pneumothorax
© Bleeding  clotting and obstruction  Hydrocephalus
(d) (+) Ultrasound
(5) Other Potential Complications:
(a) RDS
(b) Apnea
(c) Retinopathy
(d) NEC

 Nursing Diagnoses:
o Impaired Gas Exchange R/T Immature Pulmonary Function
 <32 weeks: Periodic respiration, (-) Bradycardia
 True apnea: >20 secs
 ↓surfactant  alveolar collapse
 (+) Breech  expel meconium into AF  aspiration  inflammation or
pneumonia
 (+) CS  retained lung fluid
 Give mother O2
 ↓Maternal analgesia and anesthesia
 Preterm must be resuscitated within 2 mins after birth
 Keep infant warm
 Carry out all procedures gently
 100% O2: 2 Dangers:
 Pulmonary edema
 Retinopathy of prematurity
o Risk for Deficient Fluid Volume R/T Insensible Water Loss at birth and small
stomach capacity
 Normal glucose: 40-60 mg/100 ml
 Specific gravity: 1.003 – 1.030
 UO: 1 ml/kg/hr
 IVF 160-200 ml/kg/BW  umbilical venous catheter
 Monitor weight, UO and specific gravity and electrolytes
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 Measure UO by weighing diapers
 Preterm: 40-100 ml/kg x 24 hrs ; 1.012
 Term: 10-20 ml/kg x 24 hrs ; 1.030
 Test urine for glucose and ketones
 Keep a record of all blood drawn
 Check for blood in stool
 Determine possible cause of hypovolemia
o Risk for Imbalanced Nutrition Less than Body Requirements R/T Additional
Nutrients Needed for Maintenance of rapid growth, possible sucking difficulty and
small stomach
 Feeding Schedule
 IVF  feeding may be delayed
 TPN
 Breast, gavage or bottle feeding
 Get CXR before feeding
 (+) Air in stomach
 Small, frequent feeding (1-2 ml every 2-3 hrs)
o Preterm: 115 – 140 cal/kg/ BW
o Term: 100 – 110 cal
 Gavage Feeding
 (+) Gag reflex  32 weeks
 32-34 weeks, ill, (+) RDS  Gavage feeding
 Bottle feeding or breast feeding is gradually introduced
 Give softer nipple
 Observe preterm infant closely
 Offer pacifier
 Aspirate stomach secretions  measure  replace
 >2 ml  not allowed
 (-) Digestion  NEC
 Formula:
 24 cal/oz  preterm
 20cal/oz  term
 Vit. K 0.5 ml
 Give Vit. E  prevent hemolytic anemia
 Breastmilk:
 Prevents NEC
o Ineffective Thermoregulations R/T Immaturity
 PE should be delayed
 Keep NB warm during transportation
 Heat shield or plastic wrap
o Risk for Infection
 Linen and equipment must not be shared
 Staff members must be free of infection
 Hand washing and gowning
o Risk for Impaired Parenting
 4.5 or 5.5 lb (“magic” weight)  parents are called
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 Rocking, singing and talking and gentle holding
 Kangaroo care
 Encourage the mother to express breastmilk
 Encourage mother to come to the hospital and hold the baby before and
after gavage or bottle feeding
 Photograph of baby
 Notes to convey messages from the baby to them can be taped to the
incubator
 Sibling should not visit if they have colds or fever, (+) immunization, (-)
exposure to communicable diseases
o Deficient Diversional Activity (Lack of stimulation)
 Organize procedures
 Shield from noise and light
 Pain should be kept into minimum
 Look directly at an infant in the straight forward position
 Provide some “talk time”
 Gentle stroke an infant’s back
o Risk for disorganized infant behavior
 Modify environment; reduce stimuli
 Dim the lights; cover the incubator, turn infant to the side, contain body
with rolled towels
 Offer non-nutritive sucking
 Maintain “quiet hour”
o Parental health-seeking behaviors
 Overprotection is not necessary
 Basic immunization

4) Post term
a) >42 weeks
b) Placenta functions effectively for only 40 weeks
c) (+) Postterm syndrome: SGA characteristics
i) Dry
ii) Cracked (leather like)
iii) (-) Vernix
d) Light weight
e) ↓AF, meconium stained
f) Fingernails have grown well
g) Alertness = 2 weeks old
h) BPP is done
i) CS may be indicated
j) (+) Difficulty establishing respiration
k) Hypoglycemia
l) ↓SC tissue  temperature regulation difficult
m) Polycythemia, ↑hct
n) ↓nutrition and O2  (+) Neurologic symptoms

ILLNESS IN THE NEWBORN:

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1) Respiratory Distress Syndrome (Hyaline Membrane Disease)
a) Due to ↓blood perfusion of lungs; ↓surfactant
b) (+) Hyaline like (fibrosis) membrane formed from an exudate of infants blood  lines
terminal bronchioles, alveolar ducts and alveoli  prevents exchange of O2 and CO2
c) Pathophysiology:
i) ↓surfactant  (+) areas of hypoinflation  pulmonary resistance  blood shunts to
foramen ovale and ductus arteriosus  lung perfusion  ↓↓surfactant
ii) (+) Hypoxia, ↑Co2  (+) Lactic acid  acidosis  vasoconstriction  ↓pulmonary
perfusion  ↓↓surfactant production  alveoli collapse with expiration
d) Assessment:
i) Lowbody temperature
ii) Nasal flaring
iii) Retractions
iv) Tachypnea (>60)
v) Cyanosis
vi) Expiratory grunting
vii) ↑distress
(1) Seesaw respiration
(2) Heart failure
(3) Pale, gray skin
(4) Periods of apnea
(5) Bradycardia
(6) Pneumothorax
viii) CXR: Diffuse pattern of radiopaque areas “ground glass” (haziness)
ix) Blood gas: Respiratory acidosis
x) C/S: R/O β-hemolytic group B strep
(1) May start Penicillin or Ampicillin + Gentamycin or Kanamycin
e) Management:
i) Surfactant replacement
(1) Sprayed into lungs by syringe or catheter by ET tube
(2) Head held upright and tilted downward
(3) AW should not be suctioned
(4) (+) Ventilator  needs close observation
ii) O2 administration
(1) Continuous Positive Pressure (CPAP) or Assisted Ventilation with Positive End
Expiratory Pressure (PEEP)  Keep alveoli from collaping
(2) Cx: Retinopathy of prematurity
iii) Ventilation
(1) Normal I/E ratio: 1:2
(2) Infant ventilators: 2:1
(3) Complications:
(a) Pneumothorax
(b) Impaired CO
(c) ↑ICP and arterial pressure
(d) Hemorrahge
(4) Limit fluid intake  ↓pulmonary artery pressure
(5) Indomethacin or Ibuprofen  closure of PDA
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(a) Complications:
(i) ↓Renal function
(ii) ↓platelet function
(iii)Gastric irritation
iv) Additional Therapy
(1) Muscle relaxants
(a) Pancuronium (Pavulon) IV  ↓spontaneous respiratory function
(i) ↓Pressure mechanical ventilation
(ii) ↓Pneumothorax
1. Needs critical observation
2. Frequent ABG
(iii)Atropine and Prostigmine should be available
(2) Extracorporeal Membrane Oxygenation (ECMO)
(a) Blood removed from baby by gravity advanced to RA
(i) ECMO machine  reoxygenated and warmed  carotid artery  aortic
arch
(ii) Used for 4-7 days
(iii)Cx: Intracranial hemorrhage
(3) Liquid Ventilation
(a) Use of Perflourocarbons
(b) (+) O2  Perflourocarbons pick up and carry O2  distends the lungs 
exchange of O2
(c) Can be used to deliver O2
(4) Nitric Oxide
(a) Cause of pulmonary vasodilation
v) Prevention:
(1) Sonogram
(2) Document: Lecithin should exceed Sphingomyelin (2:1)
(3) MgSO4 or Terbutaline  prevent preterm birth
(4) Steroids  ↑Lecithin
(a) Betamethasone 12-24 hrs; 24-34 wks AOG (takes effects before 24-48 hrs)

2) Transient Tachypnea of the NB

a) Birth: 80bpm when crying; 80-120 bpm, 1 hr: 30-60 bpm
b) Mild retractions, (-) cyanosis
c) Mild hypoxia and hypercapnia
d) Feeding is difficult
e) CXR: (+) Fluid in the central lung, (+) adequate aeration
f) Cause: Slow absorption of lung fluid, ↓phosphatidyl-glycerol (mature surfactant)
g) Common in CS and preterm infants
h) ↑↑RR  1st sign of obstruction
i) Peaks at 36 hrs of life, 72 hrs fades

3) Meconium Aspiration Syndrome

a) (+) Meconium at 10 weeks AOG
b) (+) Breech  expel meconium in amniotic fluid
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c) (+) Hypoxia  (+) Vagal reflex  relaxation of rectal sphincter
d) Appearance; Green to greenish black
e) May be aspirated in utero or with 1st breath
f) (+) Respiratory distress:
i) (+) Inflammation of bronchioles
ii) Mechanical plugging
iii) ↓surfactant production
g) Hypoxemia, ↑CO2, (+) shunting
h) (+) secondary infection  Pneumonia
i) Assessment:
i) ↓Apgar score
ii) Tachypnea, retractions, cyanosis
iii) Suction with bulb syringe or catheter while at the perineum
iv) Do not administer O2 under pressure
v) Enlargement of AP diameter (barrel chest)
vi) ABG: ↓pO2, ↑pCO2
vii) CXR: Bilateral coarse infiltrates in the lungs, (+) spaces of hyperaeration (honeycomb
effect)
viii) Diaphragm pushed downward
j) Management:
i) Amniotransfusion
ii) CS birth
iii) Tracheal suction, O2, assist ventilation
iv) Antibiotic therapy
v) Observe closely for signs of trapping air in the alveoli
vi) Observe for signs of heart failure due to shunting of blood from pulmonary artery to
aorta (↑HR, respiratory distress)
vii) Maintain a temperature neutral environment
viii) Chest physiotherapy
ix) ECMO

4) Apnea
a) Pause in respiration longer than 20 secs, (+) Bradycardia
b) (+) Beginning cyanosis
c) Causes:
i) Preterm: Fatigue or immature respiratory mechanism
ii) Secondary stress: infection, hyperbilirubinemia, hypoglycemia or hypothermia
d) Gently shake infant or flicking the sole of the foot
e) Resuscitation is necessary
f) May be placed on ventilator
g) Maintain neutral thermal environment
h) Gentle handling
i) Always suction gently
j) NGT
k) Observe infant carefully after feeding
l) Careful burping
m) Never take rectal temperature  bradycardia  apnea
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n) Theophylline or Caffeine Sodium Benzoate  stimulate respiration  ↑sensitivity to CO2
o) High risk of SIDS

5) SIDS
a) Unexplained death in infancy
b) Commons among:
i) Infants of adolescent mother
ii) Closely spaced pregnancy
iii) Underweight and preterm infants
iv) Bronchopulmonary dysplasia
v) Twins
vi) Narcotic dependents
c) Peak age: 2-4 mos.
d) Contributory Factors:
i) Prolonged, unexplained apnea
ii) Viral respiratory or botulism
iii) Pulmonary edema
iv) Brainstem abnormality
v) Neurotransmitter deficiency
vi) HR abnormalities
vii) Distorted familial breathing patterns
viii) ↓arousal response
ix) ↓ surfactant
x) Sleeping prone
e) Infants are well nourished
f) Slight head cold
g) Dies with laryngospasm
h) Blood flecked sputum or vomitus in mouth or on bed clothes
i) Autopsy:
i) Petechiae in the lungs
ii) Mild inflammation and congestion in respiratory tract
j) Inform parents that the death was unexplained
k) Give assurance that SIDS is a disease of infants

6) Apparent Life threatening Event

a) (+) Cyanosis, limp, survived mouth to mouth resuscitation
b) Apnea monitoring  alarms (apnea 20 secs, HR <80)
c) Parents should be taught CPR

7) Periventricular Leukomalacia (PVL)

a) Abnormal formation of white matter
b) Cause: Ischemic episode  ↓circulation to brain
c) Phagocytes and macrophages invade area
d) Sonogram: (+) Hollow space
e) Common in preterm infants
f) No therapy
g) (+) Learning disabilities
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h) Prevention:
i) Reduce environmental stimuli
ii) Avoid rapid fluid infusion
iii) Avoid sudden noises

8) Hyperbilirubinemia
a) Hemolytic Disease of the NB
i) Rh incompatibility
(1) Mother: Rh (-)
(2) Fetus: Rh (+)
(a) Sensitization: Mother begins producing antibodies against D antigen (72 hrs)
(b) 2nd pregnancy: ↑D antibody  destroy fetal RBC
(3) Requires intrauterine transfusions
(4) May induce preterm labor
(5) Administer Phenobarbital to women  speeds liver maturity
ii) ABO Incompatibility
(1) Mother: Type O
(2) Fetus: Type A or B or AB
(3) Not born anemic
(4) Hemolysis begins with birth; may continue up to 2 wks
(5) Preterm: Not affected
(6) Increase reticulocyte count
 Assessment:
o Percutaneous umbilical blood sampling
 ↑anti-Rh titer (Indirect Coomb’s test)  Mother
 (+) Abs  Fetal erythrocytes
o (-) Pale
o Enlarged liver and spleen
o (+) Edema
o Severe anemia  Heart failure (Hydrops Fetalis)
o (+) Progressive jaundice
o (+) Preterm: (+) Hemolysis  Liver cannot convert indirect to direct bilirubin
o (+) Breastfeeding: (+) Prenanediol  ↓Progesterone  interferes with
conjugation of indirect bilirubin
o Normal bilirubin: 0-3 mg/100ml
o >20mg/dl or 12 mg/dl in preterm  Kernicterus
o Hypoglycemia
o ↓Hgb
 Management:
o Early feeding  ↑peristalsis
 Bilirubin incorporated into feces
o Phototherapy
 Specialized light: Quartz halogen, cool white day light or special blue
fluorescent light
 12-30 inches above the bassinet or incubator
 Infant is undressed except for diaper
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 Term NB: Bilirubin 15 mg/dl; Preterm: 10-12 mg/dl
 Eyes must always be covered
 Stool: Bright green, loose, irritating to skin; Urine: Dark colored
 Assess skin turgor, I/O  DHN
 Monitor axillary temperature
 Infant should be removed for feeding
o Exchange Transfusion
 Aspirate stomach
 Umbilical vein is catheterized
 Draw small amounts of blood (2-10 ml)  replace with equal amounts of
donor blood
 Blood is exchanged slowly  1-3 hrs (automatic pumps)
 End: hct, bilirubin, Ca+, glucose, culture
 Repeat exchange transfusion
 Done for hyperbilirubinemia or polycythemia, blood incompatibility, ↓heart
failure
 Keep NB warm
 Blood should be given at room temperature
 Use only commercial blood warmers
 Albumin may be administered 1-2 hrs before
 Monitor rate of flow of albumin
 Blood type used: O-
 Monitor HR, RR and BP
 Blood contain acid-citrate-dextrose (ACD) as anticoagulant  ↓Ca 
acidosis
 Ca gluconate is given every 100 ml of blood
 Citrate-Phosphate Dextrose (preservative)  hyperglycemia  ↑insulin 
hypoglycemia
 Heparinized blood  interferes with clotting
 ↓glucose  hypoglycemia
 Give Protamine sulfate
 Observe infant for umbilical vessel bleeding
 (+) Redness or inflammation  (+) infection
 Report changes with V/S
 Take and record glucose 1 hr after
 Monitor bilirubin 2 or 3 days after
 May administer erythropoietin

9) Hemorrhagic Disease of the NB

a) ↓Vit K  ↓formation of prothrombin by the liver  ↓blood coagulation
b) Babies born from mothers receiving anticonvulsive meds  ↓Vit K
c) Administer Vit K to mother before birth IM
d) ↓Vit K:
i) (+) Petechiae on skin
ii) Conjunctival, mucous membrane or retinal hemorrhage
iii) Vomit fresh blood, black, tarry stools
e) Dip stick guaiac test
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f) Vit K deficiency bleeding: 2-5 days of life
g) PT prolonged, CT prolonged or normal
h) Prevention: 1 mg Vit K IM immediately after birth
i) Handle infant extremely gently
j) (+) Subdural hemorrhage may occur

10) Twin to twin transfusion

a) Monozygotic (identical; sharing same placenta) or with abnormal AV shunts
b) Donor twin: anemia, SGA, hypoglycemia, pale
c) Receiving twin: Polycythemia  Hyperbilirubinemia
d) Identified in sonogram
e) Hgb determination at birth: Difference of >5.0g/100 ml
f) Donor: Transfusion
g) Recipient: Exchange transfusion

11) Necrotizing Enterocolitis (NEC)

a) Infants in NICU
b) (+) Necrotic patches  ↓digestion  paralytic ileus
c) (+) Perforation and peritonitis
d) May be a complication of exchange transfusion

12) Retinopathy of Prematurity (ROP)

a) Acquired ocular disease  partial or total blindness
b) Due to vasoconstriction of immature retinal blood vessels
c) Endothelial cells in the periphery of retina proliferate  retinal detachment  blindness
d) Monitor blood pO2 by pulse oximeter or blood gas
e) >100mmHg  ↑risk
f) Management: Cryosurgery or laser therapy

NEWBORN AT RISK BECAUSE OF MATERNAL INFECTIONS OR ILLNESS:

1) Beta hemolytic, group B streptococcus infection (GBS)
a) Normal flora
b) Give ampicillin IV at 28 weeks and during laor
c) Assessment:
i) PROM  blood culture
ii) Early onset:
(1) Pneumonia, apnea
(2) Shock (↓UO, paleness, hypotonia)
(3) CXR: Ground glass (RDS)
iii) Late onset: (2-4 weeks) Meningitis
(1) Lethargy, fever, loss of appetite
(2) Bulging fontanelles
d) Management:
i) Gentamycin, Ampicillin, Penicillin

2) Ophthalmia neonatorum
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a) [Link] and C. trachomatis
b) Extremely serious form of conjunctivitis  corneal ulceration  opacity of cornea 
severe vision impairment
c) Assessment:
i) Generally bilateral
ii) Fiery red, thick pus
iii) Eyelids edematous
d) Prevention: Erythromycin ointment
e) Management:
i) (+) Gonococci: IV Ceftriaxone (Rocephin), Penicillin
ii) (+) Chlamydia: Erythromycin ophthalmic solution
iii) Irrigate with sterile saline solution by using sterile medicine dropper or bulb syringe
and use barrier protection (goggles)
(1) Room temperature
(2) Direct it laterally
iv) Treat mother for Gonorrhea or Chlamydia
v) Sexual contact should be treated also

3) Hepatitis B virus
a) 70-90% become chronic carriers  Liver cancer
b) Vaccinate at birth
c) Mother (+) HBsAg  Give HBIg within 12 hrs of birth
d) Bathe ASAP
e) Gentle suctioning
f) Mother may breastfeed

4) Herpes Virus
a) HSV2 can cross placenta
b) Assessment:
i) During pregnancy:
(1) (+) Vesicles covering skin
(2) Neurologic damage
ii) Birth:
(1) Loss of appetite, low grade fever lethargy
(2) Stomatitis or few vesicles on skin
(3) Vesicles are clustered, pin point, surrounded by reddened base
(4) Dyspnea, jaundice, purpura, convulsion and shock
(5) Death may occur within hours or days
c) Diagnosis:
i) Culture
d) Management:
i) Acyclovir (Zovirax)
ii) CS
iii) Separate infant with other infants
iv) Women with lesions on face should not feed or hold their NB

5) Infant with DM mother

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a) (+) Macrosomia
b) (+) Congenital anomaly (cardiac)
c) Hyperglycemia  teratogenic
d) Caudal regression syndrome (hypoplasia of lower extremities)
e) Cushingoid appearance
f) Lethergic and limp
g) (+) GH, ↑insulin  extra fat  Macrosomia
h) Immature
i) (+) RDS: ↑insulin  ↓glucose  (-) cortisol release  (-) formation of Lecithin  (-)
Lung maturity
j) “Fragile giant”
k) Complications:
i) Birth injury  CS
ii) Birth: ↓glucose  ↑insulin  severe hypoglycemia
iii) Hyperbilirubinemia
iv) Hypocalcemia due to ↓PTH
v) Hypoglycemia: Glucose <40 mg/dl
l) Management:
i) Early feeding with formula
ii) Continuous infusion of glucose
iii) May not be given bolus  rebound hyperglycemia
iv) Smaller left colon  limited oral feeding
(1) Vomiting
(2) Abdominal distention
(3) Monitor normal bowel movement

6) Drug Dependent Mother

a) SGA
b) (+) Withdrawal symptoms (neonatal abstinence syndrome)
i) Irritability, constant movements, disturbed sleep pattern
ii) Frequent sneezing
iii) Hyperreflexia and clonus
iv) Tachypnea  alkalosis
v) Tremors
vi) Shrill, high pitched cry, convulsions
vii) Vomiting and diarrhea
c) Avoid excessive stimuli
d) Darkened room
e) F/E balance, IVF
f) Antidotes:
i) Phenobarbital
ii) Methadone
iii) Chlorpromazine
iv) Diazepam
g) Treat mother for withdrawal symptoms
h) Follow up care for infant
i) Determine whether environment is safe for infant at home
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j) May have neurologic problem

7) Fetal Alcohol Syndrome

a) Alcohol crosses the placenta
b) (+) Pre and post natal growth restriction
c) Cognitive challenge
d) Microcephaly
e) Cerebral palsy
f) Short palpebral fissure
g) Thin upper lip
h) Tremulous, fidgety and irritable
i) Weak sucking reflex
j) Sleep disturbance (always awake or always asleep)
k) Mother needs follow up