HIGH RISK NEWBORN Lecture 13

1. HIGH RISK NEWBORN Lecture 13

2. LEVELS OF NICU Level I • Basic neonatal care; minimum requirement for a facility that provides inpatient maternity care. • Able to perform neonatal resuscitation. • Evaluate healthy newborns; provide standard care. • Stabilize newborns til transfer to intensive care Level II AKA Special Care Nurseries • Basic care to moderately ill infants; ~ 32 – 42 wks. • Step down from level III NICU; infants recover Level III • Newborns <32 wks, critical illness, needing surgical intervention. RN’s - intensive training; ~ 6-8 mos.

3. National studies show: • 30% survival rate for 23 wk preemies. • 52 % for 24 wks. • 76 % for 25 wks. • African American women: twice as likely to deliver early, but babies more likely to survive. High risk newborns in NICU: • Use cardiac & apnea monitors; radiant warmers; O2 sat, VS, BP monitoring. • Assessed q 1-2 hrs. or continuously • ^ risk of infections: GBS, septicemia, thrush • Moms encouraged to visit NICU daily • Skin care to prevent breakdown. • Good hand washing - parents/staff.

4. RDS – Pre-Term • Resp.distress syndrome: aka “hyaline membrane disease” • In preemie, insufficient surfactant in alveoli causing lungs to collapse; not enough O2. • Most common disorder of preemies. • ^ resistance causes fibrous tissue in bronchioles & alveoli • poor O2/CO2 exchange. • Self-limiting; ~ 72-96 hrs in most late preterm or full term. • VLBW (ELBW) - RDS can persist days/weeks. D/T immature lungs, non-compliance, and low surfactant levels.

5. Causes of RDS - Term In term infant: • Sepsis [GBS] • Persistent Pulmonary Hypertension of Newborn (PPHN) – ductus arteriosus does not close. • Meconium aspiration r/t oligo, uteroplacental insufficiency, & fetal distress • Infants of diabetic moms. • May need resuscitation @ birth. In Pre-term infant: Immature lungs, non-compliance, & low surfactant levels.

6. S/S of RDS (In PRETERM) • Retractions - drawing back of chest muscles with breathing. Infant works harder at lung expansion. • SOB and expiratory grunting –self-induced by infant - maintains ^ pressure in lungs by causing expiratory braking using vocal cords (glottis partially closes increasing alveolar surface tension) • Nasal flaring; TTN [transient tachypnea = ^ 60 R/min.] Management: • ABG’s, O2 sats, CBC, bl.cx • Skin/mouth care • Suctioning (prn) • Support for family • Adequate fluids and electrolytes • Replace surfactant [Curasurf man made; ET tube] • O2 therapy [Oxyhood; CPAP; ventilator] [CPAP= cont.+ airway pressure] helps keep small air sacs from collapsing; suction prn

7. Terms AGA - Approp. for gestational age [5.7 – 9.1] SGA - Small for gestational age. ~ < 5.7 lbs. LGA - Large for gestational age. ~ > 9.1 lbs.

8. SGA: weight < 10th percentile compared to others of same gestational age. [38 wk. weighs 5 lbs.] • Aka IUGR aka Failure to thrive. • Most common cause: placental anomaly; placenta not receiving sufficient nutrition from uterine arteries or placenta. Severe DM, pre-eclampsia, poor nutrition, smoking, cocaine. Decreases blood flow to placenta. • Fundal height lower than expected for gest.age. • Bio Physical Profile: assesses placental function. • If infant not thriving in utero, will do C/S; weigh pros/cons.

9. SGA infant: wasted look, dull hair, small liver [^^ bili’s], poor skin turgor, low glucose, low temp. Mature neuro responses, sole creases, + ear cartilage. • Lab findings: ^ HCT {low plasma levels} & ^ RBC {polycythemia} Causes thicker blood making heart work harder; ^ chance of thrombosis. Prolonged acrocyanosis. Manage: ^ fluids & freq.feedings.

10. LGA: aka macrosomic infant. > 90% percentile. Appears healthy; may be gestationally immature {immature neuro responses & respiratory effort}. Assess: larger than average uterine size for gestational age Do sono to estimate size. Check dates. C/S for CPD or shoulder dystocia. Causes: GDM, omphalocele, transposition great vessels. Appearance: possible fx clavicles; facial/head bruising, facial/neck palsy, caput, cephalohematoma. Observe: hypoglycemia, polycythemia, irregular HR, cyanosis [in transposition]

11. Preterm Infant 90% term births [full-term] & 11% preterm [< 37 wks] Calculated by gestational age; not weight. • Maturity determined by physical findings: sole creases, skull firmness, ear cartilage, neurologic findings & pregnancy dates. • SGA & Pre-terms: 2 different causes w. diff. problems. • Preterm: fetus has been doing well in utero but trigger initiates labor & infant is born early. • Problems: poor thermoregulation, hypoglycemia, intracranial bleed, RDS, NEC, immature kidney function, infection. • 80-90% of infant mortality in 1st yr. life esp. VLBW infants

12. Risk Factors of Preterm Delivery • Women of middle/upper socioeconomic: ~ 4-8% • Lower socioeconomic levels: ~ 10-20% • Inadequate nutrition; lack of money & knowledge about good nutrition; lack of support. • American Academy of Pediatrics: “live-born infant weighing 2500 g. or less”. • World Health Organization (WHO) & American College of Obstetricians and Gynecologists (ACOG) – both define it as infant born prior to 37 wks.

13. Appearance of Preterm Infant24-36 weeks • Small, underdeveloped, head disproportionately large; skin thin & ruddy [little subcut. fat]; veins noticeable; prolonged acrocyanosis. vernix depends on gest.age. • < 24 wks.vernix not formed. • None/few sole creases. • Ear cartilage immature; no quick rebound of pinna. • Extensive lanugo. • Suck/swallow absent, weak cry < 33 wks. Ballard Gestational scale to estimate age. • Infection – decreased maternal antibodies • Skin fragile; limit alcohol; rinse with water. Adhesives cause skin tearing. Use skin barriers to protect skin. Tegaderm tape. Handwashing a must !

14. **Former Extreme Premature Teen** • 13 year old female • Ex-24 week preemie • BPD, trach/vent • 15 mos in NICU • G-tube 3 yrs • Decannulated at age 4 • Intensive learning support • Eating age-typical diet • Mild articulation errors

15. Thermoregulation: • risk for hypothermia r/t large surface in relation to body weight. • Limited stores of brown fat • Decreased or absent reflex control of skin capillaries • Immature temperature regulation in brain • Kangaroo care [skin to skin contact] • Assess Respiratory Effort • May need intubation to maintain respirations. • < 32 wks: irregular respiratory pattern normal • Survanta in ET tube

16. Urinary/Elimination • Have high insensible water loss d/t large body surface compared w/ total body weight. Lower GFR d/t immature kidneys. Fluid overload or dehydration. • Strict I/O • Immature kidneys secrete glucose slowly > hyperglycemia can result.

17. Insensible Water Loss[Approx. water loss in body] • Age group Water • Premature infant 90% • Newborn infant 70-80% • 12-24 months 64% • Adult 60%

18. Nutrition: promote normal growth & development • Tries to maintain rapid rate of intrauterine growth. • Lack of cough reflex: can aspirate formula. • Have weak sucking, swallowing, gag reflexes • Weak abdominal muscles; weak gag reflex • ^ aspiration risk • ^ BMR - High caloric needs but small stomach capacity • Limited store of nutrients • Decreased ability to digest proteins and absorb nutrients, and immature enzyme systems. • TPN, PPN, Gavage, or IV feedings

19. Feeding • Caloric requirement: PT: 95-130 kcal./kg/day. • Term infant: 100-110. • Smaller stomach capacity: sm.,freq. feedings [q 2-3 hrs]. • Formula: Calories for premie: 24 cal./oz. Term: 20 cal/oz. • Breast milk good d/t immunologic properties. • Gavage: nasogastric/orogastric. Gag reflex not intact til infant 32 wks; avoid over filling stomach; may cause respiratory distress. Use premie nipple.

20. Developmentally Supportive Activities ** (new) • Kangaroo Care/Skin to Skin Care • Non Nutritive Sucking (Significantly reduced length of hospital stay for preterm infant) • Non Nutritive at the Breast (pacifer) • Parent Education & Support

21. Non-Nutritive Sucking at Breast ** • Improved milk production • Provides sucking experience • Prepares infant for breastfeeding • Long term effects: • Increased length of exclusive breastfeeding • Increased length of total breastfeeding

22. POTENTIAL COMPLICTATIONS of PT Infant Anemia of Prematurity: red blood cell life is short. Low bone marrow prod. until ~ 32 wks. Frequent blood testing. Kernicterus: destruction of brain cells by invasion of indirect bilirubin [bili ~20]. PT infants: low serum albumin available to bind indirect bili & excrete it. Persistent Patent Ductus Arteriosus: d/t hypoxia, lack of surfactant, lack of musculature. Lungs are noncompliant. ^ blood stays in pulmonary artery > pulmonary artery HTN >persistent PDA. Indocin stimulates PDA closure.

23. Bronchopulmonary Dysplasia. (Chronic Lung Disease) Results from long term O2 & being vented (PPV). Lungs immature; resp.infection, poor nutrition, Pressure damages & stretches lung tissue; results in airway edema & fibrotic buildup. Alveolar walls thicken; buildup of secretions; pneumonia & atelectasis possible. Decreased oxygenation results. • S/S: tachypnea, tachycardia, hypoxia, grunting, retractions, feeding & activity intolerance. • TX: prevent further disease; promote oxygenation, promote lung healing. • O2, nutrition, steriods, bronchodilators, diuretics, antibiotic tx; stop PPV; maintain venting @ lowest pressure. • Nitric oxide; Vitamin A

24. Neonatal Sepsis • Premies more susceptible; immature immune sys. • Transmission: viral, bacterial; transplacental (syphilis, toxoplasmosis) • S/S: low temps, resp. distress, hypotension, ^HR, ^RR, lethargy, poor feeding, diarrhea, vomiting. • Mortality: 5-20% • CBC with diff (^bands, decreased neutrophils, decreased platelets), blood cx, • TX: broad spectrum antibiotics; VS, nutrition, fluids, O2. Parental support.

25. ROP: Retinopathy of Pre-maturity. Caused by damage to immature blood vessels in retina. Results in scarring. Caused by high O2 levels. Blindness may result. 90% of cases no impairment. Occurs in VLBW <1500 g. • TX: reattachment of retina; Frequent eye evals. Laser to reduce scarring. • Nursing Care: routine high risk premie care; sepsis; VS; support groups & education

26. Intracranial Hemorrhageaka IVP • germinal matrix – made up of fragile & vascular capillaries. Grades 1-4 (3 & 4 worse) • Bleeding into ventricles d/t hypoxia, ^ BP, ^ fluids. • Dx with Cranial ultrasound • Normal brain function assessed > bleed. • IVH occurs in 20-25% of VLBW premies; suffer more severe grades of IVH • IVH is an important predictor of adverse neurodevelopmental outcome • ½-3/4 of infants with Grade 3-4 IVH develop CP & 75% in some type of special education

27. NEC NEC: necrotizing enterocolitis; common in PT baby; can result in ulcers/tissue necrosis in intestinal wall. Bacteria in bowel>infection>destroys bowel tissue> sepsis. Primary risk factor: prematurity & tube feedings; RDS, congenital heart defects. S/S abd. swelling, septic infant, emesis, blood in stool. Tx: stop tube feedings, start IVF & TPN, AB [sepsis], ventilator, platelet transfusion [control bleeding] • Prevention: Delayed /Slow feedings: advance < 20 ml/kg/day; Enteral Antibiotics; Antenatal Steroids; enteral IgG, IgA; Human Milk Feedings.

28. GDM • Infants [GDM moms] macrosomic if not well controlled during pregnancy; lethargic d/t ^ glucose. • Macrosomia: overstimulation of pituitary growth hormone in fetus in preg. d/t ^ maternal insulin. • Mom “insulin resistant”; glucose x placenta; more insulin made by fetal pancreas. • After delivery, glucose levels drop, but insulin remain ^ for several hours. Infant “jittery” on admission. Glucose checked for 1st 4 hrs; Hypoglycemia = < 40 mg/100 ml whole blood.

29. GDM Complications: Immature lungs d/t ^ fetal insulin which interferes with cortisol release; blocks formation of lecithin & prevents lung maturity. ^ chance of birth injury d/t ^ size; shoulder dystocia. Hypoglycemia: Check glucose on admission to NBN: 1, 1½, 2, 4 hrs. of life. If < 40; stat serum glucose & feed formula [1/2 oz.] Repeat in ½ - 1 hr. as protocol.

30. Transient Tachypnea of Newborn: “TTN” • Rapid, shallow RR 70-80/min. d/t slow absorption of lung fluid. • Difficulty feeding; infant will not suck d/t rapid breathing. • Chest x-ray shows fluid in lungs. • Infant must ^ resp.depth to aerate effectively. • Can signify obstruction. VS, O2 sat; give O2. • Send to NICU for close observation if not resolved within 4-6 hrs.of life. • Occurs more w. term C/S & preterm infants.

31. Meconium Aspiration Syndrome: • Present in fetal bowel as early as 10 wks. Infant may aspirate meconium in utero or with 1st breath. • Can cause severe respiratory distress, inflammation or blockage of small bronchioles by mechanical plugging • Ductus arteriosus may remain open; causes blood to shunt from pulmonary artery to aorta instead of passing thru lungs [^ pulmonary resistance], causing ^ hypoxia.

32. Symptoms • Tachypnea [RR>60] • Retractions • SOB and expiratory grunting • Nasal flaring • Periods of apnea • Bluish color of skin and mucus membranes • Arms or legs puffy or swollen Prevention • Oropharyngeal suctioning of infant > delivery • Laryngoscopic visualizaiton of vocal cords > intubation. • Additional suctioning of trachea. • Amnioinfusion: dilutes meconium. Thins out particulate meconium. Do sepsis workup; CBC, bl.cx., chest x-ray. AB therapy to prevent pneumonia.

33. SIDS: sudden infant death syndrome. • Mainly in adolescent moms, closely spaced pregnancies, underweight, PT infants. 2nd hand smoke. • Appear well nourished. ^ African American males. • Silent death; poss.laryngospasm. • Use of sleep apnea monitor for first few wks.-mos. Peak age: 2-4 mos. Cause unknown. • Theories: HR abnormalities, decreased arousal [moro] responses, prone position, low surfactant, brain stem abnorm. • In 2000 Amer. Academy of Pediatrics recommended back or side position; not prone. Incidence declined 50% since then. New data: use of pacifier for 2-4 mos.

34. Hyperbilirubinemia • ^ levels of unconjugated (indirect) bilirubin in blood. Breakdown of RBC’s > Hgb > heme > Unconjugated bilirubin. • Bilirubin binds with plasma protein (albumin) = “bound” goes to liver & converts to conjugated or H2O soluble where it ‘s excreted via bile by feces. • Immature livers which cannot convert indirect to direct; indirect bilirubin remains in bloodstream. • Unbound bilirubin = (indirect) jaundice. • If indirect level rises > 7, yellow color results. • Sclera, nail beds, then skin. • Cephalocaudal progression: head to toe. • Blanch skin • Depends on hours/days of life. • Younger infant (4-5 hrs.) high reading more significant; could rise steadily . • Older infant (1-2 days), higher # less significant (more mature liver).

35. Pathologic [within 24 hrs.] • Bili rises quickly. By 5-7 mg/dl/day or more. • Blood type incompatibilities ; sepsis; birth trauma. Interventions: Early & frequent feedings to speed up excretion in stool. Phototherapy - bilirubin becomes water soluble to be excreted. • Cover genitalia & eyes. Prevent organ damage. Single, double, triple phototherapy. • Kernicterus: Indirect bilirubin of 20 > permanent brain damage; bilirubin encephalophathy. • Signs: hi-pitched cry, seizures, hypotonia • Interventions: Immediate exchange transfusion; followed by phototherapy & frequent bili levels.

36. Physiologic Jaundice: [> 24 hrs.] 2nd-3rd day. • R/T low albumin (decreased binding sites for bilirubin). ^ levels of RBC’s. Yellowing of skin caused by breakdown of fetal red blood cells which produces excessive amts. of bilirubin in blood stream. Excess bilirubin in blood causes jaundice. • Management: frequent feedings, frequent bili levels. Bili declines within days. • Teach parents to place near window to speed up breakdown of bili. Sunlight will ^ breakdown.

37. Gastroschisis:weakness in abdominal wall causing herniation of gut on umbilical cord during early development; most commonly on right side. Viscera lie outside abdominal cavity; not covered with sac. • 1 in 4,000 live births • Mortality: 10%-15% • Assoc.w.prematurity; malrotation of intestines; decreased abdominal capacity; other anomalies rare. • TX: IV & NG tubes immediately; TPN; Silastic (synthetic covering) over viscera; surgical closure after contents returned to abd.cavity. If necrotic bowel present, remove.

38. Nursing Care: • thermoregulation (monitor temps, radiant warmer); sterile technique (cover viscera - warm, sterile, saline gauze & plastic); monitor VS, color, etc.) strict I&O, daily weights, fontanels, pacifier, electrolytes. Minimize movement of area. • encourage bonding asap; developmental stimulation for long term hosp; support group for parents; teach parents s/s bowel obstruction- ie. vomiting, pain, firm abdomen, anorexia, irritability.

39. Omphalocele:large herniation of gut into umbilical cord. Viscera outside of abd.cavity & covered with peritoneal & amniotic membranes • 1 in 5,000 to 10,000 live births • Assoc.w.malrotation of intestines; decreased abdominal capacity. Stenosis common; cardiac, genitourinary, or chromosomal anomalies common (1/3 to ½ of cases) • Mortality: 20-30%; sepsis & intestinal obstruction. • TX: same as for gastroschisis • Nursing Care: Same as for gastroschisis.

40. Bladder Exstrophy:extrusion of urinary bladder to the outside of body through developmental defect in lower abdominal wall. Assoc.w.genital anomalies: wide symphysis pubis. Rare & congenital anomaly; bladder is “turned inside out” TX: protect exposed bladder tissue; cover with saline gauze/plastic wrap til sugery. Prevent UTI. Reconstruction of bladder & genitalia. Provide support & education

41. EA (esophageal atresia) TEF (tracheo-esophageal fistula) • Cause unknown. • Congenital malformations – esophagus ends before reaching stomach. (TEF) fistula may connect to trachea. • 1 in 2,000 - 4,500 live births. 30-50% have other anomalies (cardiac, GI, nervous sys). • Premature or LBW common • EA without TEF : Inability to pass suction or NG tube catheter @ delivery. Confirm with abd.x-ray; Excessive oral secretions; vomiting; risk of aspiration; Abdominal distention; Airless/sunken abdomen. • Hx maternal polyhydramnios • TEF without EA: food enters trachea; choking; cyanosis.

42. Statistics • Esophageal atresia with distal TEF 87%Isolated esophageal atresia without TEF 8%Isolated TEF 4%Esophageal atresia with proximal TEF 1%Esophageal atresia with proximal and distal TEF 1%

43. Management: infant supinew. HOB to decrease secretions. NG tube for frequent suctioning to prevent aspiration of gastric secretions; IVF; assess VS, resp.distress, measure abd.girth; provide education & support to family. Surgical repair: fistula ligation & end to end anastomosis of atresia. Provide post op care. IVF, G-tube & foley care; pain; VS, I&O, skin care.