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• Complications of preterm birth and low birth weight are the top killers of newborn babies globally
• More than one million deaths each year result from complications of preterm birth and low birth weight
• Countless babies who survive suffer lifelong physical, neurological, or educational disability
• Almost half of children who die before their fifth birthday in the Philippines are newborns
• 60 percent of babies who die succumb to complications brought about by prematurity and low birth weight
• Recognizing high-risk newborns at birth and organizing care for them can protect their present and future health
• Information on the care of newborns who are ill or born with a significant variation in gestational age or weight is described in this module
• Infants need to be evaluated after birth to determine their weight and gestational age
• Classification by growth charts and gestational history is important to determine immediate health care needs and anticipate possible problems
• Preterm infants are born before the end of week 37 gestation
• Preterm infants are further divided into late preterm (born between 34 and 37 weeks) and early preterm (born between 24 and 34 weeks)
• Factors associated with preterm birth include low socioeconomic level, poor nutritional status, lack of prenatal care, multiple pregnancy, previous early birth, cigarette smoking, age of mother (less than 20 years old), and more
• Observing physical findings and reflex resting is used to differentiate between term and preterm newborns at birth
• Characteristics of a preterm infant include a disproportionately large head, ruddy skin with little subcutaneous fat, high degree of acrocyanosis, and more
• Dubowitz Maturity Scale is used to assess gestational age in newborns
• Post-term infants are born after the 41st week of pregnancy
• Post-term infants are at special risk due to the placenta losing its ability to carry nutrients effectively after 40 weeks
• Problems of post-term babies include difficulty establishing respirations, hypoglycemia, low subcutaneous fat levels, and polycythemia
• Anemia of Prematurity:

  • Many preterm infants develop a normochromic, normocytic anemia
  • Causes include immaturity of the hematopoietic system, destruction of red blood cells due to low levels of vitamin E, and excessive blood drawing after birth
  • Interventions include coordinating blood draws to the fewest possible, delayed cord clamping, DNA recombinant erythropoietin, Vitamin E supplement, blood transfusion, and iron supplement
• Apnea of Newborn:

  • Preterm babies, especially under 32 weeks, may have an irregular respiratory pattern
  • True apnea has a pause in respirations of more than 20 seconds with bradycardia
  • Preterm infants have difficulty initiating respirations at birth due to immature pulmonary capillaries
  • Interventions include gently stimulating the infant to breathe, positive pressure ventilation, and maintaining a neutral thermal environment
• Hyperbilirubinemia:

  • Elevated serum bilirubin levels in newborns
  • Interventions include monitoring for jaundice, keeping the newborn hydrated, early and frequent feeding, preparing for phototherapy, and monitoring closely during treatment
• Acute Bilirubin Encephalopathy:

  • Destruction of brain cells by indirect bilirubin invasion
  • Preterm infants have less serum albumin to bind bilirubin
  • Interventions include initiation of feeding, phototherapy, and exchange transfusion
• Persistent Patent Ductus:

  • Preterm infants lack surfactant, leading to difficulty in moving blood from the pulmonary artery into the lungs
  • Administer intravenous therapy cautiously and consider using indomethacin or ibuprofen to close the patent ductus
• Periventricular/Intraventricular Hemorrhage:

  • Preterm infants are prone to hemorrhage due to fragile capillaries and immature cerebral vascular development
  • Interventions include cranial ultrasound to detect hemorrhage and monitoring for long-term effects like hydrocephalus
• Respiratory Distress Syndrome:

  • Occurs in preterm infants due to low surfactant levels
  • Pathologic feature is a hyaline-like membrane that prevents gas exchange
  • Interventions include high pressure to fill the lungs with air, as surfactant does not form until the 34th week of gestation
• Pressure of lung fluid:

  • 40 and 70 cm H2O needed to inspire a first breath
  • 15 to 20 cm H2O to maintain quiet, continued breathing
• Decrease in lung surfactant production leads to cascades of events:

  1. Alveoli collapse with each expiration

  2. Areas of hypo inflation occur, increasing pulmonary resistance

  3. Shunting of blood through the foramen ovale and ductus arteriosus

  4. Tissue hypoxia causes release of lactic acid

  5. Formation of hyaline membrane on alveolar surface

  6. Acidosis causes vasoconstriction and decreased pulmonary perfusion

  7. Decreased surfactant production leads to alveoli collapse

  8. Vicious cycle continues until oxygen-carbon dioxide exchange is inadequate without ventilator support
• Prevention:

  • Dating pregnancy by sonogram and level of lecithin in surfactant
  • Using tocolytic to prevent preterm birth
  • Administering glucocorticosteroid like betamethasone to quicken lecithin formation
• Assessment:

  • Most infants with RDS have difficulty initiating respirations at birth
  • Signs include low body temperature, nasal flaring, tachypnea, and cyanotic mucous membranes
• Interventions:

  • Surfactant Replacement:
  • Restores lung surfactant to improve lung compliance
  • Administered intratracheally in 4 doses in the first 48 hours of life
  • Assess infant before and after administration
  • Oxygen Administration:
  • Necessary to maintain correct PO2 and pH levels
  • Can be administered through various methods
  • Ventilation:
  • Ventilator may have reversed I/E ratio (2:1)
  • Complications like pneumothorax and impaired cardiac output are possible
• Necrotizing Enterocolitis:

  • Gastrointestinal disease affecting premature newborns
  • Signs include distended abdomen, poor intestinal action, and occult blood in stool
• Retinopathy of Prematurity:

  • Ocular disease causing partial or total blindness in children
  • Caused by vasoconstriction of immature retinal blood vessels
• Sudden Infant Death Syndrome (SIDS):

  • Sudden unexplained death in infancy
  • Possible contributing factors include sleeping prone, viral infections, and brain stem abnormalities
• Interventions to reduce the incidence of Sudden Infant Death Syndrome (SIDS) include:

  • Avoidance of soft beddings and overheating
  • Avoidance of exposure to tobacco, alcohol, and illicit drugs
• Parents often have difficulty accepting the sudden death of a child and may experience somatic symptoms like nausea, stomach pain, or vertigo
• Counseling by a nurse or trained professional at the time of the infant's death is recommended to help parents resolve their grief
• Autopsy reports should be given to parents as soon as available to provide reassurance, especially if the cause of death is unexplained
• Parents with older children should be assured that SIDS is specific to infants and that the phenomenon will not affect older siblings
• Parents of a subsequent child after a SIDS incident should be closely monitored for anxiety and the newborn may undergo a sleep assessment within the first 2 weeks of life
• Meconium Aspiration Syndrome:

  • Meconium can cause severe respiratory distress by causing inflammation, blocking bronchioles, and decreasing surfactant production