Module No.
04
Date: March 31, 2022
Topic: The High-Risk Newborn
CUES/QUESTIONS/ NOTES
KEYWORDS
Newborn at Risk because of ALTERED GESTATIONAL AGE
Gestational age refers to no. Preterm Infant
of weeks that the infant A live born infant born before the end of 37 weeks
remained in the utero. Can be gestation
determined by:
1) MacDonald’s rule Assessment
measure of the size Ballard Score or Maturity Scale
of the uterus in cm
distance from top Complications
of the uterus to Anemia of Prematurity
symphysis pubis a baby born early does not have enough red
2) LMP (-3mos, - 7days, blood cells
+1yr) Kernicterus
type of brain damage that can result from
high levels of bilirubin in a baby's blood
Dysmature infant may be born • Persistent Patent Ductus Arteriosus (PDA)
before term or post-term, or a persistent opening between the two major
who is underweight or blood vessels leading from the heart
overweight for gestational age results from lack of surfactant, therefore,
lungs are noncompliant
surfactant is injected to inflate lungs and
Full term AOG: 37 – 42wks support breathing
Pre-term AOG: < 37wks • Periventricular/Intraventricular Hemorrhage,
Post-term AOG: > 43wks intracranial hemorrhage
• Respiratory distress syndrome (RDS)
• Retinopathy of prematurity (ROP)
• Necrotizing enterocolitis (NEC)
a serious disease that affects the intestines of
premature infants
happens within the first 2 weeks of life in
babies who are fed formula instead of breast
milk
bacteria invade the wall of the intestine
Vernix caseosa acts as a Post-term Infant
waterproof barrier to protect A live born infant born after the 42 weeks AOG
the baby's skin against the
amniotic fluid and facilitates Post-term syndrome
extra-uterine adaptation of Dry, cracked, almost leatherlike skin from lack of
skin in the first postnatal week fluid
if not washed away after birth. Absence of vernix
AF less than usual, may be meconium-stained
Long fingernails
Meconium is a newborn's first
poop Complications
Meconium aspiration
Hypoglycemia
Impaired thermoregulation
Polycythemia, dehydration
Newborn at Risk because of ALTERED BIRTH WEIGHT
Altered Gestational Age
Colorado (Lubchenco) Intrauterine Growth Chart
used to determine if the weight of infant is small,
average or large for gestational age
reference to monitor the premature newborn's
growth
Low birth weight (LBW) infants – under 2500g
Very low birth weight (VLB) – 1000-1500g
Extremely very low birth weight (EVLB) – 500-1000g
AGA Appropriate for Gestational Age
10th - 90th Percentile of weight for their age
SGA Small for Gestational Age
Below 10th Percentile of weight for their age
They experience intrauterine growth restriction
(IUGR)
failed to grow at the expected rate in utero
Uterine perfusion involves the
transport of nutrients and Risk factors
oxygen to the placenta and the Malnutrition
fetus Adolescent pregnancy
Placental anomaly – most common
Systemic diseases that decrease uterine perfusion
Smoking, narcotic use
Intrauterine infection- rubella, toxoplasmosis
Assessment
May be detected in utero – fundic height, sonogram
Acrocyanosis is blueness of At birth:
the extremities and the center Overall wasted appearance
of your face like the nose and Small liver → difficulty regulating glucose,
ears. protein, bilirubin
Poor skin turgor, appear to have a large head
relative to body size
High Hct count/polycythemia → acrocyanosis
Hypoglycemia is common
LGA Large for Gestational Age
Above 90th Percentile of weight for their age
Also termed macrosomia
Appears deceptively healthy, but immature
development
Risk factors
Mothers with GDM (gestational diabetes mellitus)
or are obese
Multiparity
Other conditions associated with LGA:
Transposition of the great vessels
Beckwith syndrome
classified as an overgrowth syndrome
affected infants are larger than normal
(macrosomia)
Omphalocele
birth defect of the abdominal (belly) wall
organs stick outside of the belly through the
belly button
Assessment
Unusually large uterus for gestational age
Difficulty or prolonged labor → shoulder dystocia
At birth:
Immature reflexes, signs of prematurity
Extensive bruising or birth injury
Caput succedaneum, cephalhematoma,
molding
Complications
Bruising
Polycythemia → cardiovascular dysfunction
Hypoglycemia
Illness in the Newborn
Transient Tachypnea of the Newborn (TTN)
Respiratory rate that remains at 80-120 bpm beyond 1
hour after birth
Cause
retained lung fluids
Assessment
Mild retractions
(-) cyanosis
Difficulty feeding
CXR, UTZ will reveal lung fluids
Risk Factors
CS birth
Extensive fluid administration of mother during
labor
Preterm infants
Management
Observe closely, WOF progression to more serious
illness
O2 prn
Peaks at 36HOL then fades, usually ends at 72HOL
Apnea
A pause in respirations longer than 20 seconds with
accompanying bradycardia
Risk factors
Presence of infection
Hyperbilirubinemia
Hypoglycemia
Hypothermia
Management
Gently stimulate the infant to breathe again
Close monitoring, document duration x episode/min
Respiratory Distress Syndrome (RDS)
Hyaline membrane disease
Pathologic feature: hyaline-like (fibrous) membrane
lines the bronchioles, alveolar ducts, alveoli,
preventing gas exchange
Caused by low level or absence of surfactant
Surfactant does not form until the 34th week
AOG
Assessment
Most infants who develop RDS have difficulty
initiating respirations at birth.
After resuscitation:
Low body temperature
Nasal flaring
Sternal and subcostal retractions
Tachypnea (more than 60 bpm)
Cyanotic mucus membranes
Grunting - caused by closure of the glottis →
increases pressure in alveoli on expiration
As distress increases:
Seesaw respirations
Heart failure, evidenced by decreased UO and
edema of extremities
Pale gray skin
Periods of apnea
Bradycardia
Pneumothorax
Diagnostics
CXR – ground glass (haziness)
ABG – respiratory acidosis
R/O group B beta-hemolytic infections
Blood, CSF, skin gs/cs
Antibiotic and aminoglycoside started while
culture reports pending: Ampicillin and
Amikacin respectively
Therapeutic Management
Surfactant replacement
Endotracheal administration
Mechanical ventilator
Oxygen administration
Mechanical ventilator
CPAP – continuous positive airway pressure
Pharmacological
Indomethacin or Ibuprofen – closure of PDA
Pancuronium IV – decrease risk of
pneumothorax
ECMO – extracorporeal membrane oxygenation
Liquid ventilation – perfluorocarbon
Supportive care: keep thermoregulated, provide
hydration and nutrition
Meconium Aspiration Syndrome (MAS)
An infant may aspirate meconium either in utero or
with the first breath at birth.
Fetal hypoxia → stimulation of vagus nerve →
relaxation of rectal sphincter
Can cause severe respiratory distress:
Causes inflammation of the bronchioles
Block bronchioles by mechanical plugging
Decreased surfactant production through lung
trauma
May lead to pneumonia
Assessment
Meconium-stained AF
Difficulty establishing respirations at birth
Low APGAR score
Tachypnea
Retractions
Cyanosis
Barrel chest
ABG: PO2, increased PCO2
CXR: bilateral coarse infiltrates in the lungs, with
spaces of hyperaeration (honeycomb effect);
diaphragm pushed downward by overexpanded
lungs
Therapeutic Management
Amnioinfusion – to dilute the meconium in AF and
reduce risk of aspiration
May have CS birth once meconium-stained AF is
detected
Suction with a bulb syringe or catheter while at the
perineum, before the birth of shoulders, to prevent
meconium aspiration.
Don’t administer oxygen under pressure (bag and
mask) until intubated and suctioned.
Post-birth and tracheal suction, oxygen
administration and assisted ventilation.
Antibiotic therapy as prophylaxis for secondary
pneumonia !!! meconium is sterile
Surfactant administration
WOF pneumothorax, pneumomediastinum, si/sx of
heart failure, hypoxia.
Maintain neutral temp environment to prevent →
metabolic oxygen demands.
Chest physiotherapy: clapping, vibration
ECMO
Sudden Infant Death Syndrome (SIDS
Sudden unexplained death in infancy
Peak age of incidence: 2-4 months old
Risk Factors
Adolescent pregnancy
Closely spaced pregnancy
Underweight, preterm infants
Infants with bronchopulmonary dysplasia
Twins
Native American, Alaskan Native
Economically disadvantaged black infants
Infants of narcotic dependent mothers
Clinical Findings
After being put to bed at night or for a nap, infant is
found dead a few hours later.
They do not appear to make a sound as they die
Many infants are found with blood-flecked sputum
or vomitus in their mouth – most likely occur as
result of death, not as a cause
Did not suffocate from bedclothes, choke from
overfeeding, underfeeding, or crying.
Client Teaching
American Academy of Pediatrics recommendation:
put newborns to sleep on their backs with pacifier
reduced SIDS incidence by 50%
Hemolytic Disease of The Newborn
Hemolysis → hyperbilirubinemia
Most common cause: ABO incompatibility
ABO incompatibility
Maternal blood type is O+, fetal blood type is
A, B, AB
Progressive jaundice usually occurs within the first 24
hours of life
Diagnostics: TB, B1, B2
Therapeutic Management
Initiation of early feeding
Phototherapy
Exchange transfusion
Nursing Considerations
Place lights 12-30 inches above the infant.
Eye and genital shield
Stool often becomes bright green, loose and
irritating to the skin. Urine may be dark-colored.
Keep thermoregulated; WOF skin breakdown
Retinopathy of Prematurity
acquired ocular disease that leads to partial or total
blindness in children
caused by vasoconstriction of immature retinal blood
vessels d/t delivery of high concentration of oxygen.
ROP screening routine for premature babies
Ophthalmia Neonatorum
Eye infection that occurs during birth or during the
first month
Most common causative agents
N. gonorrhea
Chlamydia trachomatis
Assessment
generally bilateral fiery red conjunctiva with thick
pus
edematous eyelids
Prevention
Erythromycin eye prophylaxis
Therapeutic Management
Individualized depending on organism cultured
gonococci – Ceftriaxone, Penicillin
chlamydia – Erythromycin eye ointment
Standard and contact precaution
Eye irrigation with NSS using sterile medicine
dropper or bulb syringe, administered laterally to
prevent cross-contamination
SUMMARY
Newborn at Risk because of ALTERED GESTATIONAL AGE
Preterm Infant
A live born infant born before the end of 37 weeks gestation
Assessed with Ballard Score or Maturity Scale
Post-term Infant
A live born infant born after the 42 weeks AOG
Newborn at Risk because of ALTERED BIRTH WEIGHT
Altered Gestational Age
Colorado (Lubchenco) Intrauterine Growth Chart is used to assess and classify infant’s
weight/growth
Low birth weight (LBW) infants – under 2500g
Very low birth weight (VLB) – 1000-1500g
Extremely very low birth weight (EVLB) – 500-1000g
AGA Appropriate for Gestational Age
10th - 90th Percentile of weight for their age
SGA Small for Gestational Age
Below 10th Percentile of weight for their age
LGA Large for Gestational Age
Above 90th Percentile of weight for their age
Also termed macrosomia
Appears deceptively healthy, but immature development
Illness in the Newborn
Transient Tachypnea of the Newborn (TTN)
Respiratory rate that remains at 80-120 bpm beyond 1 hour after birth
Caused by retained lung fluids
Apnea
A pause in respirations longer than 20 seconds with accompanying bradycardia
Absence of respiration
Respiratory Distress Syndrome (RDS)
Hyaline membrane disease
Pathologic feature: hyaline-like (fibrous) membrane lines the bronchioles, alveolar
ducts, alveoli, preventing gas exchange
Caused by low level or absence of surfactant
Meconium Aspiration Syndrome (MAS)
An infant may aspirate meconium either in utero or with the first breath at birth.
Fetal hypoxia → stimulation of vagal nerve → relaxation of rectal sphincter
Can cause severe respiratory distress:
Causes inflammation of the bronchioles
Block bronchioles by mechanical plugging
Decreased surfactant production through lung trauma
May lead to pneumonia
Sudden Infant Death Syndrome (SIDS
Sudden unexplained death in infancy
Peak age of incidence: 2-4 months old
Hemolytic Disease of The Newborn
Hemolysis → hyperbilirubinemia
Often caused by ABO incompatibility (Maternal blood type is O+, fetal blood type is A,
B, AB)
Progressive jaundice usually occurs within the first 24 hours of life
Retinopathy of Prematurity
acquired ocular disease that leads to partial or total blindness in children
caused by vasoconstriction of immature retinal blood vessels d/t delivery of high
concentration of oxygen.
ROP screening routine for premature babies
Ophthalmia Neonatorum
Eye infection that occurs during birth or during the first month
Commonly caused by N. gonorrhea and Chlamydia trachomatis
Administer erythromycin for prevention
