High risk neonates
Objectives
At the end of this lecture, students will be able to
• Define high risk neonates.
• Identify predisposing factors for high risk neonates
• List classification of high risk infant.
• Recognize problems associated with Pre-term, SGA, and Post-term infants.
• Perform neonatal assessment
• Admission criteria for high risk neonates.
• Common Problems of high risk neonates
A. Prematurity
B. Postmaturity
C. Hypothermia and hyperthermia
D. Hyperbilirubinemia
E. Respiratory distress syndrome
• Apply nursing management.
A. Assessment.
B. Nursing diagnosis.
Introduction
Some newborns are considered high risk. This means that a newborn has a greater chance of
complications because of conditions that occur during fetal development, pregnancy conditions of the
mother, or problems that may occur during labour and birth. Some complications are unexpected and
may occur without warning. Other times, there are certain risk factors that make problems more likely.
Identification of high-risk neonate
- The high risk neonate can be defined as a newborn, regardless of gestational age or birth weight,
which has a greater than average chance of morbidity or mortality because of threats to life and health
that occur during prenatal, perinatal or postnatal period.
- It can also be defined as a neonate exposed to any condition that makes his life in danger.
Classification of high-risk neonate
A. Classification according to size:
1- Low-birth-weight (LBW) infant: An infant whose birth weight is less than 2500g, regardless of
gestational age.
2- Very-low-birth-weight (VBW) infant: An infant whose birth weight is less than 1500g.
4 Extremely-low-birth-weight (ELBW) infant: An infant whose birth weight is less than 1000g.
B. Classification according to gestational age:
1 Premature (preterm) infant: An infant bom before completion of 37 weeks of gestation,
regardless of birth weight.
2 Full-term infant: An infant born between the beginning of the 38 weeks and the completion of the
42 weeks of gestation, regardless of birth weight.
3 Post mature (post term) infant: An infant born after 42 weeks of gestational age, regardless of
birth weight.
C- Classification according to mortality:
1- Live birth: Birth in which in the neonate manifests any heart-beat, breathes, or displays voluntary
movement, regardless of gestational age.
2- Fetal death: Death of the fetus after 20 weeks of gestation and before delivery, with absence of
any signs of life after birth.
3- Neonatal death: Death that occurs in the first 27 days of life; early neonatal death occurs in the
first week of life; late neonatal death occurs at 7 to 27 days.
4- Perinatal mortality: Describes the total number of fetal and early neonatal deaths per 1000 live
births.
5- Postnatal death: Death that occurs at 28 days to 1 year.
D- Classification according to pathophysiologic problems.
1- Associated with the state of maturity of the infant. Chemical disturbances eg: hypoglycemia,
hypocalcaemia.
Predisposing Factors to High-Risk Neonate
• Prenatal factors (maternal factors)
• Perinatal factors (During labour)
• post natal factors (infant factors)
A- Prenatal Factors:
1- High-risk pregnancy as in lack of antenatal care
2- poor socioeconomic conditions
3- Previous histories of obstetric complications as abortion, toxemias, placental insufficiency and
stillbirth
4- Intrauterine infection, toxoplasmosis, rubella, cytomegalovirus, herpes simplex (TORCH).
5- Malnutrition.
6- Medical illness of mother as diabetes mellitus, heart and kidney diseases severe infection and
thyroid diseases.
B- Perinatal Factors:
1. Complications
1 neonatal infectionof labour and delivery as prolonged rupture of membranes and caesarean section.
2. Fetal distress during labor
2 congenital anomalies
3 prematurity, post-maturity
4 low Apgar score
5 hypoglycemia
Health problems of high risk neonate
1- Premature
Definition:
Premature infants: it is an infant born earlier before 37 weeks of gestational age, smaller, the birth
weight is less than 2.500 gm, and physically and physiologically immature than full term infant due to
lack of development.
Premature Full term
Difference between full term baby and
Incidence: premature baby: Items
gm or less 2.500 gm 3.850 :2.700 weight .1
Recent estimates of the incidence
47cm >
of low birth weight suggest that approximately
cm 50
5 to 12% of all live length .2
births less than 2500 gm.
.Less than normal and has large trunk and short extremities
Normal 34:35 cm
head circumference .3
The head is large in proportion of the body
Wrinkled, waxy, red in colour Firm, elastic, pink in colour skin .4
Scanty Present subcutaneous fat .5
Excessive Little Lanugo hair .6
Not present Excessive Vernix caseosa .7
nails .8
Not extended to cover the ends of fingers and toes Extends to cover the ends of the fingers and toes
Each hair on the head is distinct hair .9
Hair on the head is fuzzy, tends to clump together
Cartilage is soft Cartilage is rigid ear .10
Has palpable nodule with erect nipple breast .11
No palpable nodule of breast tissue
position .12
Lies flat frog-like position with shoulders, elbows and knees touching mattress and Lies with arms and legs drawn up to fetal position, elbows and knees elevated from mattress
head on one side
Labia majora covers labia minora labia .13
Labia majora small and not cover labia minora
testes.14
Undescended, pigmentation of scrotal sac are absent Descended, pigmentation of scrotal sac is present
Deep longer Light jaundice .15
Absent Present reflexes .16
Not well developed Well developed creases .17
The nursing care of premature infant, so far as it differs from that the normal infant, is based on
the physiologic of prematurity.
1. Poor control of body temperature:
The temperature of the premature baby depends on the temperature of the environment to
maintain a normal body temperature due to:
1 Immaturity of heat regulating centre in the brain
2 The skin surface area of premature infant is great in proportion to his weight.
3 Lack of insulating subcutaneous fat layer which developed in the last month of gestation.
4 Poor muscular development
5 Low metabolic rate.
2. Difficult to establish respiration:
Respiration is shallow and irregular in premature infant due to:
1 Failure in the lung development (deficiency of surfactant)
2 Weakness of the thoracic cage (retraction)
3 Immature respiratory centre
4 Poor coughing reflex
5 Tendency to cyanosis due to poor oxygenation of the blood
6 Apnea due to immaturity of respiratory centre
3. Poor resistance to infection:
The premature infant is highly susceptible to infection and poor handle infection due to:
1 Poor develop globulin synthesis, antibody formation, and cellular defense.
2 Does not react to infection with fever or elevation of WBCs
3 Lack immune substances from his mother which transmitted to the fetus during the last month of
gestation.
Complications of prematurity
1 Respiratory distress
2 Retrolental fibroplasias
3 Hypoglycemia
4 Septicemia
5 Neonatal jaundice
6 Necrotizing enterocolitis
7 Anaemia
8 Liability to hemorrhage
9 Neonatal convulsions
Prevention of prematurity:
1. Avoid causes of prematurity
2. Good antenatal care
3. Genetic counseling
2 Maternal serum alpha feto protein
3 Amniocentesis
5 Ultrasonography
Fetal maturity assessment:
1 Menstrual history to calculate the gestational age
2 Ultrasound
3 Determine fetal lung maturity through F/L ratio.
Care immediately after birth:
Resuscitation in delivery room:
It includes the initial Apgar scoring system for physical condition.
Apgar score: at the first minute and 5 minute to re-evaluate physical condition, and is based on
five signs (heart rate, respiratory effort, muscle tone, reflex irritability, and color).
Goals of care in delivery room:
1 Maintain a natural thermal environment.
2 Maintain cardio-respiratory function.
3 Administer of oxygen therapy.
4 Administer medications if necessary during resuscitation such as Narcan, Epinephrine, or
''The frequently used method of determining gestational age is the simplified assessment of gestation
age by Ballard,
Admission of babies to the Neonatal Intensive Care Unit (N.I.C.U):
1 Infant requires observation at a level of transitional care.
2 Infant require immediately admission to a level of intensive care.
3 Criteria for early discharge from the NICU.
A. Infant require observation at a level of transitional care
• Infant weighing 1800-2500 gm and gestational age 34-36 weeks.
• Mild Rhesus diseases.
• Infant of diabetic mother unless severely affected.
• Maternal hyperthyroidism.
• Non life threatening congenital anomalies.
• History of aggressive resuscitation in delivery room.
• Infant born with meconium stained amniotic fluid.
B. Infant require immediately admission to a level of intensive care
• Infant less than 1800 gm or less than 34-35 gestation.
• Previous unexplained neonatal death with possible metabolic causes.
• Jaundice requires phototherapy or exchange transfusion.
• Evidence of septicemia.
• Bleeding disorders.
• Convulsions.
• Hypoglycemia requiring dextrose infusion.
C. Criteria for early discharge from the NICU:
• Infant weight more than 1800 gm, and gestational age more than 34 weeks.
• Good suckling reflex.
• Infant born by normal vaginal delivery.
• No history of asphyxia at birth.
• Absent or mild birth trauma.
• Absence ofjaundice.
• Absence of respiratory distress. Good general condition.
• No marked congenital abnormalities Nursing care of premature infant:-
3. Oxygen Administration
4. Feeding& Nutrition
5. Handling
6. Weighing
7. Administration of Medication
8. Charting intake& Output
9. Bathing
10. Care of the eyes
11. Care of the Cord
12. Kangaroo care
2-hypothermia and hyperthermia Thermoregulation
1 Thermoregulation is the balance between heat production and heat loss.
2 It is vital to the newborn and is entirely managed by nurses.
3 It is closely linked to the infant‘s survival and health status
Heat Loss Mechanisms
• Conduction: transfer of heat when two solid objects are in surface-to-surface contact
• Convection: transfer of heat between areas that are in contact with each other but that are not solid
• Radiation: transfer of heat from a warmer object to a cooler object without contact
Heat Production
The human body responds to cold in three ways:
• Voluntary muscular activity (vasoconstriction and increased movement)
• Shivering (inefficient in the term newborn)
Hypothermia
• One of the earliest signs of hypothermia is vasoconstriction.
• When a cold-stressed infant is rewarmed, skin temperature should not be warmer than core
temperature by more than 1 C.
• The nurse slows the rewarming process if the infant becomes apneic or if blood pressure decreases
Prevention of hypothermia
1. In the delivery room
• Conduct delivery in a warm room
• Immediately dry newborn with a clean soft preferably warm towel .Use another warm towel to wrap
the baby in two layers
• Keep the baby by the side of the mother (mothers' temperature will keep the baby warm)
Bathing of babies at birth is a dangerous practice and should be avoided. 2. Skin-to-skin contact (The
Kangaroo Method) "Kangarooing"
2. Bathing the baby
1 Bathing should be avoided immediately after birth. Ensure before giving bath that temperature is
normal. Preferably, give bath to normal baby on second day in summer. In winter bathing may be
avoided for several days.
2 Postpone bath till next day in term baby; no bath to babies who are sick / admitted in nursery;
Small &/or LBW baby- postpone till cord falls or preferably till weight is 2.5 kg.
3 The nurse or attendant should follow the instructions for bathing as given below:
• Use warm room and warm water.
• Bathe quickly and gently.
• Dry quickly and thoroughly from head to toe.
• Wrap in a warm, dry towel.
• Dress and wrap infant, use a cap on the head.
• Place infant close to mother.
Management of hypothermia
• Skin-to-skin contact
• Warm room or bed
• 200 watt bulb
Radiant heater or an incubator
• Monitor axillary temperature every hour till it reaches 36.5 °C, then hourly for next 4 hours, 2
hourly for 12 hours thereafter and 3 hourly as a routine.
• take measures to reduce heat loss
• start IV 10% Dextrose 60-80 ml/kg/day
• Give Inj Vit K 1 mg for term; 0.5 mg in preterm
Hyperthermia
Fever (temperature above 37. 5°C) is a sign of infection usually in term neonate. In all febrile neonates,
a diligent search for a possible infective focus must be made. In summer months, hyperthermia may
occur due to raised environmental temperature.
Management of hyperthermia
This may be treated by moving the baby into cool environment and using loose light clothes for the
baby. When the temperature is 37.5°C-39°C, undressing and exposing the neonate to room temperature
is usually all that is necessary. If the temperature is above 39°C, the neonate should be undressed and
sponged with tepid water at approximately 35°C until the temperature is below 38°[Link] times in
nursery overheating under warmer is the cause rather than infection. Do not use cold/ice water for
sponge. Tap water is enough
3-Respiratory Distress Syndrome (RDS)
Definition: Respiratory distress syndrome (RDS) is another name for hyaline membrane disease
(HMD). It is defined as ineffective respiratory
function resulting from lack of pulmonary surfactant, which is a substance, coats the lining of the
alveoli to facilitate alveolar expansion, and contraction.
Incidence:
1- Respiratory distress syndrome is the major cause of death in the neonatal period. It estimated that
50% of all neonatal deaths result from hyaline membrane disease and its complications.
2- The disease occurs early in premature neonates. It occurs in 60% of neonates less than 28 weeks.
3- In 15-20% of those between 32-36 weeks and in about 5% beyond 37 weeks and rarely at term
except in the infant of diabetic mother (IDM).
Pathophysiology:
- The pathologic features of RDS are a hyaline-like fibrous membrane; this membrane prevents
exchange of oxygen, and carbon dioxide at the alveolar capillary membrane
- The poor exchange leads to tissue hypoxia, which causes the release of lactic acid and increasing
carbon dioxide level.
- This process resulting from the formation of the hyaline membrane
on the alveolar surface, leads to sever acidosis, and causes pulmonary vasoconstriction and decreased
pulmonary perfusion from
vasoconstriction further limits surfactant production.
- The ability to stop alveoli from collapsing becomes difficult. This vicious process continues until
the oxygen - carbon dioxide exchange in
the alveoli is no longer adequate to sustain life without ventilator support.
Clinical pictures
1 Tachypnea, respiratory rate greater than 60 cycles per minute
2 Chest retractions
3 Flaring of nostrils
4 Expiratory grunting
5 Cyanosis
6 copious pharyngeal secretions
Diagnosis
1- Appearance, color, and breathing efforts
2- Chest x-rays of lungs
3- Blood gases (tests for oxygen, carbon dioxide and acid in arterial blood) - often show lowered
amounts of oxygen and increased carbon dioxide.
4- Echocardiography: sometimes used to rule out heart problems that might cause symptoms similar
to HMD. Shows abnormal rhythms
Disease progresses
1- Flaccidity
2- Unresponsiveness
3- Frequent apnea episodes
4- Diminished breath sound
Complications of RDS
Babies with RDS sometimes develop complications of the disease or problems as side effects of
treatment:
1- Pneumomediastrinum - air leaks into the mediastrinum.
2- Pneumothorax - air leaks into the space between the chest wall and the outer tissues of the lungs.
3- Pneumopericardium - air leaks into the sac surrounding the heart.
4- Pulmonary interstitial emphysema (PIE) - air leaks and becomes trapped between the alveoli, the
tiny air sacs of the lungs.
5- Chronic lung disease, sometimes called bronchopulmonary dysplasia
Prevention of RDS
Giving the mother medications called corticosteroids before delivery has been shown to dramatically
lower the risk and severity of RDS in the baby. These steroids are often given to women between 24 -
34 weeks gestation who are at risk of early delivery.
Treatment:
1 Treatment of neonates with RDS is largely supportive
2 Improve blood pressure, cardiac output, and renal perfusion
3 Penicillin should be given to all neonates with RDS, because of the difficulty to distinguish between
early onset of streptococcal infection, sepsis, or other respiratory disorders.
4 Administer exogenous surfactant replacement therapy can be reduce the severity of neonatal RDS.
4-High-risk related to maternal condition
Infant of Diabetic Mother (IDM)
The morbidity and mortality rates of IDM have been reduced due to effective control of maternal
diabetes and an increased understanding of fetal disorders.
There are two types of diabetes that occur in pregnancy:
1- Gestational diabetes - when a mother who does not have diabetes before becoming pregnant
develops a resistance to insulin because of the hormones of pregnancy.
2- Pre-existing diabetes - women who already have insulin-dependent diabetes and become pregnant.
Definition:
An infant of a diabetic mother is a baby born to a mother who has diabetes. The phrase specifically
refers to a baby who is born to a mother who had persistently high blood sugar (glucose) levels during
pregnancy.
Symptoms:
The infant is usually large for gestational age. Other symptoms may include: Blue or patchy (mottled)
skin color, rapid heart rate, rapid breathing (signs of immature lungs or heart failure)
• Newborn jaundice (yellow skin)
• Poor feeding, lethargy, weak cry (signs of severe low blood sugar)
• Puffy face
• Reddish appearance
• Tremors or shaking shortly after birth
Treatment:
• All infants who are born to mothers with diabetes should be tested for low blood sugar
(hypoglycemia), even if they have no symptoms.
If an infant had one episode of low blood sugar, tests to check blood sugar levels will be done over
several days. This will continue until the infant's blood sugar remains stable with normal feedings.
Early feeding may prevent low blood sugar in mild cases. Persistent low blood sugar is treated with
sugar (glucose) given through a vein.
• Rarely, the infant may need breathing support or medications to treat other effects of diabetes. High
bilirubin levels are treated with light therapy (phototherapy), or rarely, by replacing the baby's blood
with blood from a donor (exchange transfusion).
5- Hyperglycemia and hypoglycemia Hyperglycemia
Most infants who are preterm or ill require parenteral administration of glucose because adequate
enteral feeding is delayed. Hyperglycemia is often defined as blood glucose >125 mg/dL (6.9 mmol/L)
or plasma glucose >150 mg/dL (8.3 mmol/L). Hyperglycemia may be related stress and sever
prematurity to These glucose levels are frequently observed
during glucose infusions in newborns, especially in extremely preterm infants, and may need lower
sugar concentration in IVF and May need insulin
Hypoglycemia
Hypoglycemia is a common neonatal problem. Hypoglycemia is controversial. No plasma glucose level
can be defined as appropriate for every infant because the significance of hypoglycemia may depend
upon the infant's gestational and postnatal age, as well as other risk factors. In addition blood sugar
<40-50 mg/dl.
The management of Hypoglycemia: For the term baby in no sign of distress: Early feeding usually
with formula or breastfeeding Follow-up blood sugar 30 min to 1 hour after feeding Continue to
monitor blood sugar according to hospital policy.
For a term baby in distress:
Management will be with IV fluids or gavage feeding depending on symptoms
For a preterm baby: IVF - (initial fluids)
6-Neonatal jaundice
Definition:
Neonatal jaundice is a yellowing of the skin and other tissues of a newborn infant
Pathophysiology:
When RBCs are destroyed, the breakdown products are released into the circulation, where the
hemoglobin splits into two fractions: hema and
globin (protein).Protein portion is used by the body and the hema portion is converted to unconjugated
bilirubin, an insoluble substance bound to albumin. In the liver the bilirubin is detached from the
albumin molecule and in the presence of enzyme gluycuronyle transferees is conjugated with
glucuronic acid to produce a highly soluble substance, conjugated bilirubin which is then execreted
into the bile. Bacterial action reduces the conjugated bilirubin, to urobilinogen, the pigment that gives
stool its characteristic colour, most of the reduced bilirubin excreted through the feces; a small amount
is eliminated in the urine. Normally the body is able to maintain a balance between the destruction of
RBCs and the use or the excretion of the products, however, when development limitation or a
pathologic process interferes with the this balance, bilirubin accumulates in the tissues to produce
jaundice. Jaundice in babies usually occurs because their immature livers are not efficient at removing
bilirubin from the blood stream.
Types of jaundice:
• unconjugated hyperbilirubinemia: potentially toxic; may be physiological or pathological
• Conjugated hyperbilirubinemia: non toxic; always pathological.
Complication of hyperbilirubinemia:
Kernicterus:
Definition:
Kernicterus describes the yellow staining of them brain cells that may result in bilirubin
encephalopathy. The damage occurs when the serum concentration reaches toxicity levels, regardless
of the cause. Kernicterus develops when unconjugated bilirubin passes the blood brain barrier and
is deposited in the brain cells particularly the basal ganglia. This occurs when the levels of
unconjugated bilirubin exceeds 20mg/dl in term infants but at somewhat lower levels in preterm and
those suffering from asphyxia or sepsis.
Management of hyperbilirubinemia:
1 Early feeding lowers bilirubin level by stimulating peristalsis.
2 Increase feeds in volume and calories
3 Stop drugs that interfere with bilirubin metabolism
4 Correct hypoxia, infection and acidosis
5 Phototherapy
6 Exchange transfusions
Phototherapy
Definition:
2 It is the application of fluorescent light to an infant's exposed skin.
3 The light is at wavelengths of 425:475nm/sec and is blue, green or white.
4 The light causes a breakdown of bilirubin by a process of photooxidation.
5 It alters the structure of bilirubin to a soluble form (lumirubin) for easier excretion.
Indications for phototherapy:
1 In infants<1500grams, if bilirubin exceeds 5mg/dl.
2 Infants between 1500-2000grams, if bilirubinexceeds8-12mg/dl
3 Infants between2000-2500grams, if bilirubin>13-15mg/dl.
4 In formula fed neonate, if bilirubin>15-20mg/dl.
5 In breast fed neonate, if bilirubin>20mg/dl.
Side effects of phototherapy:
1 Dehydration due to increased insensible water loss.
2 Watery diarrhea
3 Hypocalcaemia
4 Retinal damage
5 Bronze baby syndromes
6 Retinal damage
7 Erythema
8 Cell damage and mutation
9 Disruption of maternal/infant interaction
Nurse’s role in phototherapy
1 The lamp should be 5-8Cs over incubator.
2 Continue feeding.
3 Shield infant's eyes
4 Keep infant nude except for diaper area and change position frequently.
5 Clean skin frequently to prevent irritation
6 Maintain adequate fluid intake to prevent dehydration and calculate intake and output.
7 Monitor body temperature to prevent hyperthermia
8 Weight infant daily
9 Observe skin, mucous membranes and stool.
10 Bilirubin levels should be monitored for at least 24 hours after discontinuing phototherapy.
Exchange transfusion
Indication:
If the preterm infant does not respond to phototherapy, exchange transfusion may be indicated.
Complications
1 Embolism, thrombosis, infarction
2 Electrolyte disturbances
3 Infections
4 Rash
5 Arrhythmia, heart failure, arrest
6 Thrombocytopenia
7 Hypothermia and hyperthermia
Nurse's role in exchange transfusion:
1 Keep infant NPO24h before exchange transfusion to prevent aspiration.
2 Check donor blood cards for compatibility
3 Have resuscitation equipment available at bedside: oxygen, amubag, endotraceal tubes and
laryngoscope.
4 Assist physician with exchange transfusion procedure
5 Monitor the amount of blood withdrawn and transfused to maintain balanced blood volume and
monitor for hypoglycemia.
6 Maintain body temperature to avoid hypothermia and stress
7 Monitor vital signs and observe for rash.
8 After transfusion continue to monitor vital signs and check umbilical cord for bleeding or signs of
infection.
7-Neonatal sepsis
Definition:
Neonatal sepsis is an infection that when bacteria or their poisonous products, known as endotoxins,
gain access to the blood stream. Septicemia refers to generalized bacterial infection in the bloodstream.
Signs and symptoms of neonatal sepsis:
General signs
1- The infant generally is not doing well
2- Poor temperature controls with hypothermia or rarely hyperthermia Circulatory system
1- Pallor, cyanosis
2- Cold, clammy skin
3- Hypotension
4- Edema
3- Grunting
5- Irregular heartbeat, bradycardia, tachycardia Respiratory system
1- Irregular respiration, apnea or tachypnea
2- Cyanosis
4- Dyspnea
5- Retractions
Gastrointestinal system
1- Poor feeding
2- Vomiting
3- Diarrhea or decreased stooling
4- Abdominal distention
5- Hepatomegaly
6- Hemoccult-positive stools
7- Hematopoietic system
8- Jaundice
9- Pallor
10- ecchymosis
11- splenomegaly
Diagnostic measurement:
1- Blood cultures
2- Urine culture
3- Trachea culture
4- Cerebrospinal fluid culture