:

• High-risk newborn


  A newborn, regardless of gestational age or birth, who has a greater-than average chance of morbidity or mortality, usually because of conditions beyond the normal events related to birth and the adjustment to extrauterine life
• Classification according to size

  • Low-birthweight (LBW): less than 2500g
  • Very low-birthweight (VLBW): less than 1500g
  • Extremely low-birthweight (ELBW): less than 1000g
  • Appropriate-for gestational-age (AGA): 10th-90th percentile
  • Small-for-date (SFD) or Small-for-gestational age (SGA): below 10th percentile
  • Intrauterine growth restriction (IUGR): restricted intrauterine growth
  • Large-for-gestational age (LGA): above 90th percentile
• Classification according to gestational age

  • Preterm (premature): before 37 weeks
  • Full-term: 38-42 weeks
  • Post-term: after 42 weeks
  • Late-preterm: 34-36 weeks
• Classification according to mortality

  • Live birth
  • Fetal death: after 20 weeks, no signs of life
  • Neonatal death: first 27 days, early: first week, late: 7-27 days
  • Perinatal mortality: fetal and early neonatal deaths per 1000 live births
  • Postnatal death: 28 days to 1 year
• Assessment of the high-risk newborn

  1. Apgar scoring

  2. Thorough, systematic physical assessment: general, respiratory, cardiovascular, gastrointestinal, genitourinary, neurologic-musculoskeletal, temperature, skin

  
• Newborn priority needs (management)

  • Initiation and maintenance of respirations
  • Establishment of extrauterine circulation
  • Control of body temperature
  • Intake of adequate nourishment
  • Establishment of waste elimination
  • Prevention of infection
  • Establishment of an infant-parent relationship
  • Developmental care
• Small-for-gestational age (SGA) infant


  Birthweight below 10th percentile on intrauterine growth curve, may be preterm, term or post-term, experienced intrauterine growth restriction (IUGR)
• Etiology of SGA


  • Prenatal nutrition
  • Placental anomaly
  • Systemic maternal disease
  • Smoking/narcotics during pregnancy
  • Intrauterine fetal infection
  • Chromosomal abnormality
• SGA infant assessment


  • Below average weight, length, head circumference
  • Small liver
  • Poor skin turgor
  • Large head, small body
  • Widely separated skull sutures
  • Dull, lusterless hair
  • Sunken abdomen
  • Dry, yellow-stained umbilical cord
  • Better developed neurologic responses
  • Sole creases and ear cartilages
• SGA infant laboratory findings

  • High hematocrit
  • Increased red blood cells
  • Hypoglycemia
• Large-for-gestational age (LGA) infant


  Birthweight above 90th percentile on intrauterine growth chart, appears healthy at birth but has immature development
• Etiology of LGA


  • Maternal diabetes
  • Multiparity
  • Other conditions: TGV, Beckwith syndrome, congenital anomalies
• LGA infant assessment


  • Large size
  • Immature reflexes and low gestational age exam scores
  • Extensive bruising or birth injury
  • Caput succedaneum, cephalhematoma, or molding
  • Cardiovascular dysfunction
  • Hyperbilirubinemia
  • Polycythemia
  • Cyanosis
  • Hypoglycemia

  
• Assessment criteria for birth injuries

  • Ecchymosis, jaundice, erythema
  • Extremity motion and Moro's reflex for clavicle fracture or Erb's palsy
  • Asymmetry of anterior chest or unilateral lack of movement for diaphragmatic paralysis
  • Eyes for unresponsive/dilated pupils, vomiting, bulging fontanelles, high-pitched cry for increased ICP
  • Jitteriness, lethargy, uncoordinated eye movements for seizure activity

  
• Premature/preterm infant


  Born before 37 weeks gestation, low in birth weight
• Factors associated with prematurity

  • Low socioeconomic level
  • Poor maternal nutrition
  • Lack of prenatal care
  • Multiple pregnancy
  • Previous premature births
  • Maternal smoking
  • Young maternal age
  • Birth order
  • Closely spaced pregnancies
  • Maternal reproductive system abnormalities
  • Infections
  • Obstetric complications
  • Early labor induction
  • Elective cesarean section
• Premature infant assessment


  • Small, underdeveloped appearance
  • Disproportionately large head
  • Ruddy skin
  • Vernix caseosa (24-36 weeks) or absence (<25 weeks)
  • Extensive lanugo
  • Small fontanelles
  • Immature ear cartilage
  • Absent sucking/swallowing reflexes (<33 weeks)
  • Less active, rarely cries
• Potential complications of prematurity

  • Anemia of prematurity
  • Kernicterus
  • Patent ductus arteriosus
  • Periventricular/intraventricular hemorrhage
  • Respiratory distress syndrome
  • Apnea of prematurity
  • Retinopathy of prematurity
  • Necrotizing enterocolitis

  
• Postmature/postterm infant


  Delivered after 42 weeks of pregnancy or exceeding 294 days
• Postmature infant assessment


  • Dry, cracked skin
  • Absence of vernix caseosa
  • Recent weight loss
  • Grown fingernails beyond fingertips
  • Alertness like 2-week-old
• Potential complications of postmaturity

  • Meconium aspiration syndrome
  • Hypoglycemia
  • Polycythemia
• Respiratory distress syndrome (RDS)


  Serious lung disorder caused by immaturity and inability to produce surfactant
• RDS incidence


  • LBW: 30%
  • VLBW: 50%
• RDS assessment


  • Low body temperature
  • Nasal flaring
  • Sternal and subcostal retractions
  • Tachypnea (>60 breaths/min)
  • Cyanotic mucous membranes
  • Seesaw respirations
  • Heart failure
  • Pale gray skin
  • Periods of apnea
  • Bradycardia
  • Pneumothorax
• RDS diagnostic findings


  • Chest radiograph: diffuse radiopaque haziness
  • ABG: respiratory acidosis
  • Culture: blood, CSF, skin to rule out infection
• RDS therapeutic management


  • Surfactant replacement
  • Oxygen administration
  • Ventilation
  • Indomethacin or ibuprofen
  • Muscle relaxants (pancuronium)
  • ECMO
  • Liquid ventilation
  • Nitric acid
  • Supportive care: warmth, hydration, nutrition
• RDS nursing management


  • Assess vital signs, O2 saturation, breathing, skin color, nutrition, glucose
  • Monitor and maintain respiratory support
  • Maintain neutral thermal environment
  • Administer enteral feedings
  • Administer surfactant
  • Encourage parental involvement
• Meconium aspiration syndrome (MAS)

  Occurs when meconium is present in infant lungs during or before delivery, caused by fetal distress
• MAS assessment


  • Immediate: low Apgar, tachypnea, retractions, cyanosis
  • Course bronchial sounds
  • Enlarged anteroposterior chest (barrel chest)
• MAS laboratory/diagnostic studies


  • ABG: decreased PO2, increased PCO2
  • Chest radiograph: bilateral coarse infiltrates, hyperaeration, downward diaphragm
• MAS management


  • Suctioning
  • Ventilatory support: O2, surfactant, ECMO
  • IV fluids
  • Antibiotic therapy: ampicillin, gentamycin, amikacin
• MAS nursing management


  • Monitor vital signs, O2 saturation, lung sounds
  • Observe for heart failure
  • Maintain temperature-neutral environment
  • Chest physiotherapy
• Apnea of prematurity


  Lapse of spontaneous breathing for 20 seconds or longer, or shorter pauses with bradycardia or desaturation
• Classification of apnea


  • Central apnea: absence of respiratory effort
  • Obstructive apnea: airflow stops due to upper airway obstruction
  • Mixed apnea: combination of central and obstructive
• Apnea of prematurity nursing management

  • Gentle shaking or flicking sole of foot
  • Resuscitate if unresponsive
  • Apnea monitor
  • Maintain neutral environment
  • Decrease fatigue
  • Gentle suctioning
  • Observe after feeding
  • Theophylline treatment
  • High risk for SIDS - monitoring device
• Neonatal sepsis


  Generalized infection in the bloodstream of the neonate, acquired in utero or during perinatal period
• Types of neonatal sepsis

  • Early-onset sepsis: onset <3 days, acquired perinatally
  • Late-onset sepsis: onset >3 days, acquired postnatally

  
• Most common infecting organisms: Term - Group B streptococcus, Preterm - Escherichia coli
• APNEA


  Airflow stops because of upper airway obstruction, yet chest or abdominal wall movement is present
• MIXED APNEA


  Combination of central and obstructive apnea. Most common form of apnea in premature infants.