CONCEPT, ASSESSMENT, GOALS, OBJECTIVES OF HIGH RISK NEWBORN

INTRODUCTION
A newborn should have a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the normal newborn course or identify a medical condition that should be addressed (e.g., anomalies, birth injuries, jaundice, or cardiopulmonary disorders) . This assessment includes review of the maternal, family, and prenatal history and a complete examination. Depending upon the length of stay, another examination should be performed within 24 hours before discharge from the hospital.

The high-risk period begins at the time of viability (the gestational age at which survival outside the uterus is believed to be possible, or as early as 23 weeks of gestation) up to 28 days after birth and includes threats to Life and health that occur during The prenatal, perinatal, and postnatal periods.

CONCEPT OF HIGH RISK NEWBORN

MEANING OF NEONATE
From birth to under four weeks of age (<28 days), the infant is called neonate or newborn. First week of life (<7 days or <168 hours is known as early neonatal period. Late neonatal period extends from 7th to < 28th day.

DEFINITION OF HIGH RISK NEWBORN

A newborn regardless of gestational age or birth weight, who has a greater than average chance of morbidity or mortality because of conditions or circumstances superimposed on the normal course of events associated with birth and the adjustment to extrauterine existence. Encompasses human growth and development from the time of viability 28 days following birth and includes threat to life and health that occur during the prenatal, perinatal, and postnatal periods.

CLASIFICATION OG HIGH RISK NEWBORN

High-risk infants are most often classified according to birth weight, gestational age, and predominant pathophysiologic problems. The more common problems related to physiologic status are closely associated with the infants state of maturity and usually involve chemical disturbances (e.g., hypoglycemia, hypocalcemia) and consequences of immature organs and systems (e.g., hyperbilirubinemia, respiratory distress, hypothermia).

CLASSIFICATION ACCORDING TO SIZE Low-Birth-Weight (LBW) InfantAn infant whose birth weight is less than 2500 g (5.5 lb), regardless of gestational age Very LowBirth-Weight (VLBW) InfantAn infant whose birth weight is less than 1500 g (3.3lb) Extremely LowBirth-Weight (ELBW) InfantAn infant whose birth weight is less than 1000 g (2.2 lb) Appropriate-For-Gestational-Age (AGA) InfantAn infant whose weight falls between the 10th and 90th percentiles on intrauterine growth curves. Small-For-Date (SFD) Or Small-For-Gestational-Age (SGA) InfantAn infant whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. Intrauterine Growth Restriction (IUGR)Found in infants whose intrauterine growth is retarded (sometimes used as a more descriptive term for the SGA infant) Large-For-Gestational-Age (LGA) InfantAn infant whose birth weight falls above the 90th percentile on intrauterine growth charts

CLASSIFICATION ACCORDING TO GESTATIONAL AGE Preterm (premature) infantAn infant born before completion of 37 weeks of gestation, regardless of birth weight Full-Term InfantAn infant born between the beginning of 38 weeks and the completion of 42 weeks of gestation, regardless of birth weight

Posterm (Postmature) InfantAn infant born after 42 weeks of gestational age, regardless of birth weight Late-Preterm InfantAn infant born between 34 and 36 weeks of gestation, regardless of birth weight

CLASSIFICATION ACCORDING TO MORTALITY Live BirthBirth in which the neonate manifests any heartbeat, breathes, or displays voluntary movement, regardless of gestational age Fetal DeathDeath of the fetus after 20 weeks of gestation and before delivery, with absence of any signs of life after birth Neonatal DeathDeath 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 Perinatal MortalityDescribes the total number of fetal and early neonatal deaths per 1000 live births Postnatal DeathDeath that occurs at 28 days to 1 year after birth

CLASSIFICATION ACCORDING TO BIRTH WEIGHT Low Birth Weight - Birth weight less than 2500g regardless of gestational age Moderately Low Birth Weight - birth weight is between 1501g to 2500g. Very Low Birth Weight -birth weight is less than 1500g. Extremely Low Birth Weight - birth weight less than 1000g.

CLASSIFICATION ACCORDING TO SIZE Appropriate for Gestational Age (AGA) - birth weight falls between the 10 and 90 percentile Small for Gestational Age ( SGA) - birth weight falls below the 10 percentile Large for Gestational Age (LGA)- birth weight falls above the 90 percentile

MEDICALLY HIGH RISK NEWBORN (MHRN) ELIGIBILITY CRITERIA

PREMATURITY (less than 32 weeks gestation) VERY LOW BIRTH WEIGHT (less than 1500 grams) SIGNIFICANTLY SGA (small for gestational age) failure to thrive, IUGR (intrauterine growth retardation) less than 5th percentile. PROLONGED hypoxemia, academia, repetitive apnea, required assisted ventilation .40 hours. METABOLIC PROBLEMS, i.e hypoglycemia, hypocalcemia HYPERBILIRUBINEMIA (considered when persistent and untreated

hyperbilirubinemia requires exchange transfusions and/or is associated with congenital anomalies). NEONATAL SEIZURES or seizures beyond the neonatal period. SERIOUS BIOMEDICAL FACTORS i.e. CNS bleeds, RDS (respiratory distress syndrome) confirmed infection, chronic lung disease. MULTIPLE CONGENITAL ANOMALIES requiring special services, but with presumed potential for normal developmental outcome.

HISTORY OF MATERNAL CHEMICAL EXPOSURE and/or substance abuse i.e. alcohol hydantoin, warfarin and cocaine. PERSISTENT FEEDING PROBLEMS PERSISTENT TONAL PROBLEMS CONTINUED evidence of delay in one or more developmental areas and poor parentinfant attachment.

IDENTIFICATION OF HIGH RISK NEWBORNS

Maternal diabetes Maternal narcotics during labor Maternal substance abuse Fetal asphyxia Difficult/prolonged labor causing birth trauma Multiple gestation Preterm or postterm delivery Congenital anomalies Maternal or neonatal infection SGA or LGA Apgar score < 6 at 1 min or < 7 at 5 min

PRETERM INFANTS
MEANING - An infant born before term (<=36 weeks); A low birth weight infant: </=13002000g (Philippine Standards) (,2.5kg) A newborn born before complete maturity; born before body and organ system have completely matured is called prematurity.

INCIDENCE: Highest among low socio economic class Largest - of admission to NICU 12% of all pregnancies CAUSES Unknown Maternal Factor Malnutrition Preeclampsia (toxemia of pregnancy) Chronic Medial illness (Cardiac/kidney disease/DM) Infection (UTI, vaginal infection) Drug Use (coccaine, tobacco, alcohol)
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 Abnormal structure of the uterus Previous Preterm Births Pregnancy Related Causes Hypertension Incompetent Cervix Placental Previa/ Abruptio Placenta PPROM, poly/oligohydramnios Fetus Chromosomal abnormalities Intrauterine Infection Anatomic Abnormalities IUGR Multiple gestations DIAGNOSTIC EVALUATION Appraisal is made as soon as possible after admission to the nursery. HEAD Head circumference is large in comparison with chest (reflects cephalocaudal direction of growth) The fontanels are small and bones are soft - Soft cranium subject to characteristic nonintentional deformation. Bones of skull and ribs - soft Very small and appear scrawny, EYES Absent eyebrows Eyes closed EARS Ears are poorly supported by cartilage (soft and pliable)

SKIN Bright pink (often translucent) with small blood vessels Smooth and shiny (may be edematous) with small blood vessels clearly visible underneath thin epidermis Fine lanugo hair abundant over body, sparse, fine & fuzzy on head Less subcutaneous fat (skin is wrinkled) SOLES AND PALMS Minimal creases HARLEQUIN COLOR Skin color changes when preterm infant is moved; Upper half or one side of the body is pale or one side of the body is red. CHEST Small breast bud size with underdeveloped nipples GENITALIA Male Infants - few scrotal rugae, undescended testes Female infants- Labia and clitoris are prominent in females POSTURE Complete relaxation with marked flexion and abduction complete relaxation with marked flexion and abduction of the thighs; Random movements are common with slightest stimulus ACTIVITY Inactive and listless

EXTREMITIES Extremities maintain an attitude of extension and remain in any position in which they are placed. REFLEXES partially developed Sucking absent, weak or ineffectual; swallow, gag, cough reflexes - ABSENT TEMPERATURE INSTABILITY Heat regulation poorly developed in the preterm infant because of poor development of CNS IMMUNITY Increased susceptibility to infection RESPIRATION Respirations are not efficient because of muscular weakness of lungs and rib cage and limited surfactant production; Retraction at xiphoid is evidence of air hunger Infants should be stimulated if apnea occurs HMD/RDS, chronic lung disease, BPD, apnea of prematurity CIRCULATION Greater tendency toward capillary fragility in the preterm infant Red and white blood cell counts are low with resulting anemia during first few months of life. NEUROMUSCULAR Neuro - Higher incidence of intracranial hemorrhage in the preterm infant Muscle twitching, convulsions, cyanosis, abnormal respirations, and a short shrill cry Cerebral palsy, visual -motor deficits, altered intellectual functions
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GASTROINTESTINAL TRACT Nutrition is difficult to maintain because of weak sucking and swallowing reflexes, small capacity of stomach, and slow emptying time of the stomach RENAL Reduced glomerular filtration rate results in decreased ability to concentrate urine and conserve fluid. Higher ECF, vulnerable to fluid and electrolyte imbalance PREVENTION Prenatal Care Good nutrition and education Identification of mothers at risk Educate on symptoms of PT labor Avoid heavy/repetitive work or standing long periods of time TREATMENT Oxygen, IVF Umbilical catheterization Intravenous Fluid Medications Blood Intravenous Fluid extraction X-ray Special feedings of breast milk/formula Kangaroo care NURSING CARE Maintain airway Check respirator function if employed Position to promote ventilation
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Suction when necessary Maintain temperature of environment Administer oxygen only if necessary Observe for changes in respirations, color, and vital signs Check efficacy of Isolette Maintain heat, humidity, and oxygen concentration; monitor oxygen carefully to prevent retrolental fibroplasias Maintain aseptic technique to prevent infection Monitor for hypoglycemia ,hyperbilirubinemia & hemorrhage Careful skin care & positioning to prevent breakdown Adhere to the techniques of gavages feeding for safety of the infant Observe weight -gain patterns Determine blood gases frequently to prevent acidosis Institute phototherapies by letting them verbalize and ask questions to relieve anxiety Provide flexible and liberal visiting hours for parents as soon as possible Allow parents to do as much as possible for the infant after appropriate teaching Arrange follow-up before and after discharge .

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POSTMATURE INFANTS
MEANING Baby born after 42 weeks AOG/ 294 days past 1st day of mothers LMP; regardless of birth weight is referred to as postmature infants. OTHER NAMES- Post term, post maturity, prolonged pregnancy, post datism

INCIDENCE 7% (3.5 -15%) of all pregn ancies CAUSES Unknown History of >/= 1 previous post term pregnancies Miscalculated due date (not sure of LMP) Fetal Risk Progressive placental dysfunction placenta (supplies nutrient & oxygen) ages toward the end of pregnancy ---may not function efficiently Amniotic fluid volume decreases, fetus may stop gaining weight/ weight loss Decreased amniotic fluid may lead to cord compression during labor

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 Increased risk of MAS and hypoglycemia Increasing size (mainly length) & hardening of skull may contribute to CPD GRE ATEST RISK: during stresses of labor & delivery especially in infants of primigravidas. CHARACTERISTICS OF INFANTS Absent lanugo, Little if any vernix caseosa, Abundant scalp hair, Overgrown nails Dry, peeling skin (cracked, parchmentlike & desquamating) Wasted physical appearance (reflects intrauterine deprivation) Minimal fat deposit (depleted subcutaneous fat) thin, elongated appearance Meconium staining - seen in skin folds w/ vernix caseosa Visible creases palms/ soles DIAGNOSIS: Physical Examination Ultrasound Scanning Non -stress testing Estimate amniotic fluid volume MANAGEMENT Check respiratory problems related to meconium Suctioning Blood test for hypoglycemia PREVENTION Accurate due date and Ultrasound Scanning Cesarean section/ induction of labor -recommended.

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HIGH RISK RELATED TO PHYSIOLOGIC FACTORS

HYPERBILIRUBINEMIA
MEANING- Hyperbilirubinemia refers to excessive level of accumulated Bilirubin in the blood JAUNDICE or ICTERUS- yellowish discoloration of skin, sclera, nails. Relatively benign but it can also be pathologic

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PATHOPHYSIOLOGY RBC Destruction

Globin

Heme

Protein (used by the body)

Unconjugated Bilirubin

Liver

Bilirubin detached from albumin through enzyme glucoronyl transferase or glucoronic acid

Conjugated Bilirubin

Excreted into Bile (feces and urine)

Hyperbilirubinemia - Result from increased unconjugated/ conjugated bilirubin Bilirubin - one of the breakdown products of one of the breakdown products of hgb from RBC destruction Unconjugated Bilirubin - insoluble, bound to insoluble, bound to albumin Intestines (or) bacterial action - reduces conjugated bilirubin Urobilinogen - pigment that gives stool its characteristic odor.

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COMPARISION OF MAJOR TYPES OF UNCONJUGATED HYPERBILIRUBINEMIA PHYSIOLOGIC JAUNDICE BREAST-FEEDING ASSOCIATED JAUNDICE (EARLY ONSET) CAUSE Immature functionor hepatic Decreased milk intake Possible increased related to fewer breast factors milk is Blood antigen BREAST MILK JAUNDICE (LATE ONSET) HEMOLYTIC DISEASE

that incompatibility causes

bilirubin load from calories consumed by prevent RBC hemolysis infant before mothers conjugation milk is

bilirubin hemolysis of large # less of RBCs. Liver unable to conjugate and excess form

well frequent stooling

established enterohepatic shunting

excrete bilirubin hemolysis.

ONSET After (preterm prolonged) PEAK 75- 90 hours DURATION Declines on 5th 7th Variable day May remain jaundiced Dependent on severity x 3-12 weeks or more and treatment 3rd 5th day 10th 15th day Variable 24 hours 2nd- 4th day infants, 5th 7th day During 1st 24 hrs

(levels increase faster than 5mg/day)

THERAPY Increase frequency of Frequent feedings and avoid 12x/day) (10 Increase frequency of Monitor TcB/TSB risk

breast breast feeding; use no level.

Perform

supplements. Evaluate feeding, avoid glucose supplementations

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assessment

stooling Monitor transcutaneous

pattern. water, supplements formula.

water (glucose or cessation Evaluate breastfeeding pattern; recommended. Perform assessment.

water): POSTNATALof phototherapy; not administer IVIG per protocol; risk perform transfusion. (fetus) if severe, exchange

bilirubin (TcB)/ Total stooling Serum (TSB) THERAPY : Perform assessment. phototherapy bilirubin

Bilirubin stimulate as needed.

risk Use phototherapy if Consider performing PRENATAL Use bilirubin level additional transfusion G6PD, prevent indirect (Rh bilirubin, of history

if increases significantly evaluations: level (17-22 mg/dl) or direct and

sensitization

incompatibility) Rhnegative with Rhig

increases significantly significant hemolysis serum (>5mg/dl/day) or is present. family

and mother (Rhogam)

significant hemolysis is present

others as necessary.

BREAST FEEDING . ASSOCIATED JAUNDICE (EARLY ONSET) THERAPY: If phototherapy is instituted, May

BREAST MILK JAUNDICE (LATE ONSET)

HEMOLYTIC DISEASE

include

home PRENATAL if mother Is assist with

evaluate benefits and harm of phototherapy with a temporary breastfeeding, temporarily breastfeeding;

discontinuing (10-12hr) discontinuation of a maintenance and storage of additional breastfeeding, a subsequent milk; may bottle-feed

assessments may be required. TSB may be drawn to evaluate expressed milk as appropriate Assist mother with a drop in serum levels. mother to therapy. infant Minimize separation contact as

maintaining milk supply, feed Assist

with maternal-

expressed milk as appropriate. maintenance of milk supply and

encourage

After discharge, follow up and reassurance regarding her appropriate. according to hour of milk supply and therapy.

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discharge.

Use formula supplements only at practitioners discretion.

CAUSES Physiologic (developmental) factors (prematurity): Excess production of bilirubin - Hemolytic disease, biochemical defects, bruises Hemolytic disease - blood antigen incompatibility blood antigen incompatibility, hemolysis of RBC; liver unable to conjugate & excrete excess bilirubin from hemolysis PHASES OF PHYSIOLOGIC JAUNDICE 2 PHASES: TERM INFANTS 1ST phase - Bilirubin: 6mg/dl on 3rd day Date Of Labour : decreased to 2--3mg/dl by 5th day 2nd phase - Steady plateau without increase/decrease level 12th -14th day: levels decreased to normal (1mg/dl) Pattern varies according to racial group, method of feeding, gestational age PRETERM: Bilirubin - 10-12mg/dl at 4-5days slowly decrease by 2-4 weeks. CLINICAL MANIFESTATIONS Jaundice most obvious sign Yellowish discoloration: sclera, nails, skin If it appears within 1st 24 hours: hemolytic disease of Newborn, sepsis, maternallyderived diseases (DM, infections) Appears on 2nd or 3rd day, peaks on 3rd 4th day, declines on 5th 7th day: physiologic jaundice (varies according to ethnicity) Intensity of jaundice is not always related to the degree of hyperbilirubinemia

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BREASTFEEDING JAUNDICE (Early onset) Early onset Begins at 2--4days of age; 12-13% of Breastfeeding infants Related to process of breastfeeding, results from decreased caloric & fluid intake by Breastfeeding infants before milk supply is well-established (fasting is associated with decrease established (fasting is associated with decreasehepatic clearance of bilirubin) Feeding (or) peristalsis more rapid passage of meconium more rapid passage of meconium decreased amount of reabsorption of unconjugated bilirubin Feeding introduces bacteria to aid in reduction of bilirubin to urobilinogen Colostrums, natural cathartic, facilitates meconium evacuation BREAST MILK JAUNDICE (late onset) Late onset : 4th -7th day of age; 12-13% of Breastfeeding infants Rising levels peak at 2nd week gradually diminish. May remain jaundiced x 3-12 weeks or more 12 weeks or more infants are well May be caused by factors in Breast Milk (pregnanediol, fatty acids, B- glucorinidase) that either inhibit conjugation or decrease excretion of bilirubin Less frequent stooling by Breastfeeding infants may allow for extended time for reabsorption of bilirubin from stools Excess production of bilirubin - Hemolytic disease, biochemical defects, bruises DIAGNOSITC EVALUATION Serum Bilirubin (B1: 0.2-1.4mg/dl) Jaundice appears at >5mg/dl Evaluation based on: Timing of appearance of clinical jaundice Gestational age at birth Age in days since birth Family history including maternal Rh factor Evidence of hemolysis Infants physiologic status Progression of serum bilirubin levels
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Persistent jaundice over 2 weeks in full-term, formula fed term, formula fed infant Total serum bilirubin levels 12.9mg/dl (term infant) or over 15mg/dl (preterm); upper limit for breastfeeding infant 15mg/dl Increase serum bilirubin >5mg/dl/day Direct bilirubin (B2) 1.5 -2mg/dl Total serum Bilirubin over 95th percentile for age (in hours)on hour--specific risk nomogram Transcutaneous Bilirubinometry , noninvasive monitoring of bilirubin via cutaneous reflectance mechanisms; allow for repetitive estimations of bilirubin Hour specific Serum Bilirubin Levels predict newborn at risk for rapidly rising levels Recommended by AAP for monitoring healthy Newborn >35wks AOG before discharge from hospital Carbon monoxide indices in exhaled breath CO is produced when RBC is broken down TREATMENT: Postnatal Phototherapy - main form Exchange transfusion - reduce high bilirubin levels that occur with hemolytic disease

Prenatal Transfusion (fetus) Phenobarbital hemolytic disease; effective when given to mother several days before delivery COMPLICATIONS Bilirubin Encephalopathy/ Kernicterusneurons o Syndrome of severe brain damage due to deposition of unconjugated bilirubin in brain cells (extremely high B1 level increase crosses the blood -brain barrier) Kernicterus- yellow staining of brain cells that may result in bilirubin encephalopathy brain injury
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unconjugated bilirubin highly toxic to the

Metabolic acidosis Low serum albumin level Intracranial infections (meningitis) Abrupt increase in BP Conditions that increase metabolic demands for oxygen and glucose - fetal distress, hypoxia, hypothermia, hypoglycemia

PROBLEMS RELATED TO BIRTH TRAUMA

FACIAL PARALYSIS From pressure on facial nerve during delivery Affected side unresponsive when crying Resolves in hours/days ERBS PALSY (ERB- DUCHENNE PARALYSIS) Associated with stretching or pulling head away from shoulder during delivery Signs: Flaccid arm, elbow extended, hand rotated inward, Moro & grasp reflexes absent on affected side Requires immobilization & reposition for 2 to 3 hrs

FRACTURED CLAVICLE Bone most frequently fractured during delivery Associated with CPD Signs: limited ROM (range of motion), crepitus, absent Moro reflex on affected side Heals quickly, handle gently, immobilize arm

ASPHYXIA Inadequate tissue perfusion Signs: acidotic scalp or cord pH

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Low Apgar score (< 4 at 1 min) Begin resuscitation immediately

NEONATAL RESPIRATORY DISTRESS Common causes o Preterm infants (Primarily associated with infants < 37 wks) o Meconium aspiration syndrome (MAS): o Transient tachypnea of the newborn (TTN): delayed fluid absorption in lungs. Signs o Tachypnea o Intercostal retractions o Nasal flaring o Expiratory grunting, diminished breath sounds o PaO2 <50, PCO2 >60 o Central cyanosis (late finding) Interventions o Radiant warmer or isolette to maintain neutral thermal environment & prevent cold stress; oxygen demands increase if neonate is cold. o Warmed, humidified oxygen o Withhold feedings if RR > 60 breaths/min o Position side lying or supine with neck slightly extended o Suction the baby to maintain a patent airway o Monitor oxygen saturation and/or ABGs as ordered

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MECONIUM ASPIRATION SYNDROME (MAS)

Prenatal asphyxia causes relaxation of anal sphincter & passage of meconium into amniotic fluid

Fetus/infant inhales meconium into airway Forms mechanical obstruction; air can be inhaled but cant be exhaled

Lungs become hyper inflated

Irritating to airway

Causing chemical pneumonitis

Signs: o Fetal distress o Apgar score < 6 at 1 & 5 min, o Distended o Barrel-shaped chest, o Diminished breath sounds, o Yellow staining of skin, nails & cord

Interventions o Suction oropharynx & nasopharynx after head is born & shoulders and chest still in birth canal o Endotracheal suctioning indicated before stimulating respirations unless infant crying & vigorous o Administer O2 and anticipate need for ventilation o Perform chest physiotherapy routinely

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TRANSIENT TACHYPNEA OF THE NEWBORN (TTN) Failure to clear airway of excess fluid at delivery Primarily term infants, especially if C/S (miss mechanical squeeze of vaginal delivery) Signs: o Grunting o Flaring o Mild cyanosis o Tachypnea, - respirations can be as high as 100 to 140 breaths/min Nursing Management o O2 as needed to maintain PO2 o Usually resolves within 72 hours

COLD STRESS All newborns at risk for hypothermia Keep temp 97.6-99.2 by Neutral thermal environment o Delay bath until temperature stable o Dry iimmediately after bath o Under warmer or skin to skin after delivery o Wrap with warm blankets o Check O2 sat and blood glucose o Chronic hypothermia can be early sign of sepsis

HYPOGLYCEMIA Blood glucose < 40 mg/dl in term newborn At risk o IDM (Infant of a Diabetes Mellitus) o SGA (Small for Gestational Age) o Premature o Infants with cold stress
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o Hypothermia o Delayed feedings Signs: o Tremors o Jitteriness o Lethargy o Decreased muscle tone o Apnea o Anorexia Nursing Management o Check blood glucose of at-risk infants,(30 min if IDM) & on any symptomatic newborn. o Feed (breast or bottle) o Reassess glucose before next feeding

INFANT OF A DIABETIC MOTHER (IDM)

Maternal glucose crosses placenta

Fetal pancreas secretes more insulin to metabolize glucose

Increased insulin decreases surfactant production.

Signs o LGA (Large for Gestational Age) o Hypoglycemia o RDS (Respiratory Distress Syndrome) o False positive L/S ratio, o Increased risk for congenital anomalies (especially cardiac and spinal)

Nursing Management
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o Assess for birth trauma o Monitor Blood glucose at 30 min and 1, 2, 4, 6, 9 12 and 24 hours o Treat hypoglycemia

NEWBORN SEPSIS Group B streptococcus most common cause Complicated by immature immune system & lack of IgM Associated with PROM Prolonged labor Maternal infection.

Signs: o Lethargy o Seizure activity o Pallor o Hypothermia o Poor feeding o Respiratory distress o Apnea o Tachycardia o Bradycardia o Hyperbilirubinemia

Nursing Management: o Obtain cultures (blood, urine, CSF) o Start antibiotics star. After 72 hrs, o Treatment stopped if culture negative & asymptomatic. o Continue antibiotics for 1014days if culture reports positive

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FETAL ALCOHOL SYNDROME (FAS) Alcohol crosses placenta

Interferes with protein synthesis

Increasing risk of congenital anomalies,

Mental deficiency & IUGR

Signs o SGA o Small eyes o Flat midface o Long, thin upper lip o Flat upper lip groove o Irritable o Hyperactive o High pitched cry

Nursing Management o Reduce environmental stimuli o Swaddle to increase feelings of security o Sedatives for withdrawal side effects

NEONATAL ABSTINENCE SYNDROME (NAS) Etiology o Repeated intrauterine drugs exposure causes fetal drug dependency, degree of withdrawal depends on type & duration of addiction

Signs o Hyperactivity, jitteriness & shrill, persistent cry

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o Frequent yawning & sneezing, nasal stuffiness o Sweating o Absence of step & head-righting reflex o Developmental delays o Feeding difficulties (vomiting, regurgitation, diarrhea) increased need for nonnutritive sucking

Nursing Management o Position infant on side to facilitate drainage of mucus o Suction PRN to maintain patent airway o Decrease environmental stimuli, swaddle for comfort o Intake & output, daily weight o Obtain meconium and/or urine for drug screening o Meds may include paregoric elixir, thorazine &Valium, methadone, phenobarbital o Pacifier for non-nutritive sucking o Dont give Narcan to infant born to narcotic addict

INTENSIVE CARE FACILITIES FOR HIGH RISK NEWBORN

Rapid advances in our understanding of the pathophysiology of the neonate and increased capacity to apply this knowledge have emphasized the need for appropriate settings in which to care for the seriously ill infant. Advancements in electronics and biochemistry, new methods for monitoring cardiorespiratory function, microtechniques for biochemical determination from minute quantities of blood, noninvasive monitoring, and new methods for assisted ventilation and conservation of body heat have made it possible to effectively manage the newborn with serious illness. Intensive care of the ill and immature newborn requires specialized knowledge and skill in a number of areas. Much of the equipment used in the care of the critically ill adult is unsuited to the singular needs of the very small infant; therefore equipment has been modified to meet these needs. Examples of modifications include ventilators that deliver small volumes of oxygen

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in the proper concentration and pressure, infusion pumps that accurately deliver very small amounts, and radiant heat warmers that provide a constant source of warmth and allow maximum access to the infant. Most important, advances in intensive care have created a need for highly skilled personnel trained in the art of neonatal intensive care. The diversity of special care needs requires that the unit be arranged for graduated care of the infant population. There should be adequate facilities and skilled personnel to provide one-toone nursing care for each seriously ill infant, as well as a means for graduation to one-to-three or one-to-four nursing care in a quieter area where infants require less intensive care until they are ready to be discharged to home. Family-centered care and a relatively quiet environment are often difficult to provide in a busy neonatal intensive care unit (NICU); therefore some units have developed step-down units and single room units where high-risk infants may be observed by skilled staff. Such areas are designed for family-centered care along with appropriate neuro developmental care.

ORGANIZATION OF SERVICES The most efficient organization of services is a regionalized system of facilities within a designated geographic area. Neonatal intensive care facilities may provide three prescribed levels of care with special equipment, skilled personnel, and ancillary services concentrated in a centralized institution (American Academy of Pediatrics and American College of Obstetricians and Gynecologists, 2007):

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Level I facilityProvides management of normal maternal and newborn care. Level IIA facilityProvides a full range of maternity and newborn care and can provide care to infants born at more than 32 weeks of gestation and weighing more than 1500 g (3.3 lb) who are moderately ill with problems that are expected to resolve rapidly and who are not anticipated to need subspecialty care; or who are convalescing after intensive care. Level IIB facilityIn addition to the above, can provide mechanical ventilation for up to 24 hours and can provide continuous positive airway pressure (CPAP). Level III facilityNeonatal intensive care o Level IIIA units provide care for infants with birth weight of more than 1000 g (2.2 lb) and gestational age of more than 28 weeks. Life support is limited to conventional mechanical ventilation. o Level IIIB units can provide care for extremely lowbirth weight (ELBW) infants with technology including high frequency ventilation and inhaled nitric oxide, onsite access to pediatric medical subspecialists, and advanced diagnostic imaging and pediatric surgery available. o Level IIIC units have the capabilities of a level IIIB NICU and, in addition, offer extracorporeal membrane oxygenation (ECMO) and surgical repair of serious congenital cardiac malformations.

TRANSPORTING HIGH-RISK NEWBORNS When an at-risk infant is identified or anticipated, arrangements are made for care in the intensive care facility. The uterus is the ideal transport unit for the infant with anticipated difficulties; therefore, whenever possible, take the mother where special care is available for her delivery. Some infants develop difficulties after a seemingly normal pregnancy and uncomplicated labor. Because it is impossible to always predict when infants will require intensive care, a coordinated System is needed to ensure them an optimum opportunity for survival. Each hospital that delivers infants should be able to provide for appropriate neonatal stabilization and arrange for transport to a tertiary care facility.

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The infant must be kept warm, be adequately oxygenated (including intubation if indicated), have vital signs and oxygen saturation monitored, and, when indicated, receive an intravenous (IV) infusion. The infant is transported in a specially designed incubator unit that contains a complete life-support system and other emergency equipment that can be carried by ambulance, van, plane, or helicopter. The transport team may consist of one or more of the highly trained persons from the NICU: a neonatologist (or a fellow in neonatology), a neonatal nurse practitioner, a respiratory therapist, and one or more nurses. The professional assigned to accompany the infant must be constantly alert to every change in the infants condition and able to intervene appropriately. The neonate who must be moved from one place to another within the hospital (e.g., to surgery, or from delivery room to nursery) is transported in an incubator or radiant warmer and accompanied by the necessary personnel and equipment.

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NURSING MANAGEMENT

COMMON NURSING DIAGNOSIS Impaired Gas Exchange Risk for Fluid Volume Deficit Risk for impaired Nutrition Risk for Infection Risk for Altered Parenting Diversional Activity Deficit Risk for Disorganized Infant Behavior

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MANAGEMENT OF HIGH RISK INFANT PHYSICAL ASSESSMENT THERMOREGULATION- need neutral thermal environment, use brown fat CONSEQUENCES OF COLD STRESS- hypoxia, metabolic acidosis, hypoglycemia GLUCOSE & CALCIUM PROTECT FROM INFECTION HYDRATION- IVF for calories, electrolytes & H2O NUTRITION- no coordination of sucking until 32-34 weeks; not synchronized until 3637 weeks; gag reflex not developed until 36 weeks EARLY FEEDING- within 3-6 hours BREAST FEEDING GAVAGE FEEDING- <32 wks. or <1500g SKIN CARE OF PREMATURE- increased sensitivity & fragile MEDICATION - caution DECREASE STRESS DEVELOPMENTAL INTERVENTION BEFORE 33 WEEKS- minimum stimulation 34-36 WEEKS- stimulate senses but dont tire out

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ASSESSMENT OF NEWBORN
INTRODUCTION At birth the newborn is given a cursory yet thorough assessment to determine any apparent problems and identify those that demand immediate attention. This examination is primarily concerned with the evaluation of cardiopulmonary and neurologic functions. The assessment includes the assignment of an Apgar score and an evaluation for any obvious congenital anomalies or evidence of neonatal distress. The infant is stabilized and evaluated before being transported to the NICU for therapy and more extensive assessment. A thorough, systematic physical assessment is an essential component in the care of the high-risk infant. Subtle changes in feeding behavior, activity, color, oxygen saturation (Spo2), or vital signs often indicate an underlying problem. The preterm infant, especially the ELBW infant, is not able to withstand prolonged physiologic stress and may die within minutes of exhibiting abnormal symptoms if the underlying pathologic process is not corrected. The alert nurse is aware of subtle changes and reacts promptly to implement interventions that promote optimum function in the high-risk neonate. The nurse notes changes in the infants status through ongoing observations of the infants adaptation to the extrauterine environment. Observational assessments of the high-risk infant are made according to the infants acuity (seriousness of condition); the critically ill infant requires close observation and assessment of respiratory function, including continuous pulse oximetry, electrolytes, and blood gases. Accurate documentation of the infants status is an integral component of nursing care. With the aid of continuous, sophisticated cardiopulmonary monitoring, nursing assessments and daily care can be coordinated to allow for minimum handling of the infant (especially the very lowbirth-weight [VLBW] or ELBW infant) to decrease the effects of environmental stress.

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The newborn requires thorough skilled observation to ensure a satisfactory adjustment to the extrauterine life. Physical assessment following delivery can be divided into 4 phases: 1. The initial assessment using an Apgar scoring system. 2. Transitional assessments during the periods of reactivity. 3. Assessment of gestational age. 4. Systematic physical examination.

INITIAL ASSESSMENT: APGAR SCORING One significant assessment of the neonate is APGAR SCORING as described by DR Virginia Apgar. Despite its limitations, it is a useful quantitative assessment of neonates condition at birth especially for the respiratory, circulatory and neurological status. Five objective criterias are evaluated at one minute and five minutes, after the neonates body is completely born. The criterias are respiration, heart rate/minute, muscle tone, reflex irritabi lity and skin color. Each of these criteria is an index of neonates depression or lack of it at birth and is given score of 0,1 or 2. The scores from each of the criteria are added to determine the total score. The neonate is the best possible condition if the score is 10. Scores of 7-10 indicate no difficulty in adjustment in extrauterine life. Scores of 4-6 signify moderate difficulty and if the score is 3 or below, the neonate is in severe distress which must be treated immediately.

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SIGN
HEART RATE RESPIRATORY EFFORT MUSCLE TONE

0
absent absent

1
Slow <100 Irregular slow weak cry

2
>100 Good strong cry

limp

Some flexion of extremities

Well flexed

REFLEX IRRITABILITY COLOR

No response

Grimace

Cry. Sneeze

Blue, pale

Body pink extremities blue

Completely pink

Total score = 10 No depression Mild depression Severe depression : 7-10 : 4-6 : 0-3

TRANSITIONAL ASSESSMENT: PERIOD OF REACTIVITYDuring the initial 24 hours, changes in heart rate respiration, motor activity, color, mucus production and bowel activity occurs in an orderly, predictable sequence that is normal and indicates lack of stress. First period of reactivity: During the 1st 30 minutes the infant is very active, alert, cries vigorously, sucks the fist greedily, and appears very interested in the environment. Neonates eyes are wide open thus, is an excellent opportunity for mother, father and child to see each other.

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Because the newborn has a vigorous suck this is the best time to begin breastfeeding.

Heart rate= 180/mt Respiration= 80/mt Bowel sounds are active. Second stage of first reactive period: Lasts for 2-4 hours. Heart rate, respiration decreases. Temperature continues to decrease. Undressing and bathing is avoided during this time. Mucus production decreases. Urine and stool generally not passed. Baby in a state of sleep and is calm.

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Second period of reactivity: Lasts for next 2-5 hours. Heart rate and respirations increases. Alert and responsive. Gastric, respiratory secretions increased. Passage of meconium frequently. After this stage is a stage of stabilization of physiologic systems. ASSESSMENT OF GESTATIONAL AGE One of the most satisfactory method for predicting mortality risks and providing guidelines for the management of newborn is the classification of infants at birth by both birth weight and the gestational age. Appropriate for gestational age Large for gestational age Small for gestational age Assessment of gestational age is mandatory for all neonates for further management. Last menstrual period is important clue for calculation of gestational age, but it may not be reliable in menstrual irregularities or mother may not remember the exact date. The clinical assessment is more practically significant. Physical and neurological examinations are done to detect the gestational maturity.

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Physical Characteristics Hair and distribution on scalp Skin texture Shiny

Preterm

Transitional

Term

texture Wooly fuzzy and very Fine wooly, fuzzy fine

Silky, black coarse and individual strands

oily

plethoric, Less

shiny,

peripheral Pink, scanty lanugo and are

and opacity

plenty of lanugo, edema cyanosis, less lanugo and only large veins

with visible veins and veins are only found on seen. Good elasticity or venules on abdomen Breast and abdomen turgor More than 10mm

nodule Breast tissue less than 5 Breast tissue 5-10 mm nipple mm on one or both sides. No nipple present

Nipple present but not diameter raised Breast tissue and nipple raised above skin level

formulation

Ear cartilage

Pinna feels soft with no Some cartilage and no recoil

cartilage

present Pinna definite

is

firm

with and

and some recoil

cartilage

instant recoil Planter creases Faint red marks over Creases seen over anterior Entire sole covered with anterior part of sole or may be absent Genitalia [male] Scrotum small with no or Scrotum with some rugae Atleast few rugae and one testis
1/ 3

to of sole

deep creases

light and testis in the inguinal descends in the scrotum. Testis canal Prominent rugae and

pigmentation.

usually not descend or in inguinal canal Genitalia [female] Labia majora widely Labia majora over

deep pigmentation

partially Labia majora completely the cover the labia minora and clitoris

separated with prominent cover labia minora and clitoris labiaminora

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Assessment of maturity of the neonates is fairly reliable on the basis of physical characteristics. But they are of limited value to assess the gestational age in less than 36 weeks of maturity. The neurological characteristics are more reliable for the precise assessment of maturity. The neurological assessment is performed based on four fundamental observations, i.e. muscle tone, joint mobility, certain automatic reflexes and fundus examination. The muscle tone of the newborn baby is assessed by three parameters, i.e. posture or attitude, passive tone [popliteal angle]and scarf sign and active tone [traction response and recoil] The joint mobility is less in preterm babies. A term baby has more flexible and relaxed joint. The degree of flexion at ankle and wrist [square-window] is limited due to stiffness of joints in early gestation. Certain auto9matic reflexes like moro reflex, papillary response to light, blink response to glabellar tap, grasp response, neck flexors, rooting reflex with coordinated suckling efforts are assessed to detect the specific age of gestational maturity based on appearance of these reflexes. The fundamental examination for disappearance of anterior vascular capsule of lens is done to assess the gestational age. In infants less than 28 weeks, the anterior capsule is completely vascularized and after 34 weeks of gestational life, the vessels are almost atrophied. This examination is difficult due to non-co-operation and photophobia of the neonate. With the scoring system of the neurological assessment the accurate estimation of gestational age can be done. New Ballard score is widely used. Neuromuscular maturity is assessed by the test like posture, square window [wrist], arm recoil, popliteal angle, scarf sign and heel to ear, using the new Ballard scoring system. Physical maturity is assessed with this system by the characteristics like skin, lanugo, planter surface, breast, eye/ear and genitals.

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TESTS USED IN ASSESSMENT OF GESTATIONAL AGE: POSTURE: With infant quite and in supine position, observe degree of flexion in arms and legs. Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and legs=4 SQUARE WINDOW: With thumb supporting back of arm below wrist, apply gentle pressure with index finger and third fingers on dorsum of hand without rotating infants wrist. Measure angle between base of thumb and forearm. Full flexion (hand lies flat on ventral surface of forearm)=4 ARM RECOIL: With infant supine, fully flex both forearms on upper arms, hold for 5 seconds; pull down on hands to fully extend and rapidly release arms. Observe rapidity and intensity of recoil to a state of flexion. A brisk return to full flexion=4 POPLITEAL ANGLE: With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex thigh on abdomen. While holding knee with thumb and index finger, extend lower leg with index finger of other hand. Measure degree of angle behind knee (popliteal angle). An angle of less than 90 degrees=5 SCARF SIGN: With infant supine, support head in midline with one hand; use other hand to pull infants arm across the shoulder so that infants hand touches shou7lder. Determine location of elbow in relation to midline. Elbow does not reach midline=4 HEEL TO EAR: With infant supine and pelvis flat on a firm surface, pull foot as far as possible up toward ear on same side. Measure distance of foot from ear and degree of knee flexion (same as popliteal angle). Knees flexed with a popliteal angle of less than 10 degrees =4
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NEW BALLARD SCORING SYSTEM Neuromuscular maturity is assessed by: Posture Square window Arm recoil Popliteal angle Scarf sign Heel to ear

SUBSEQUENT OR FOLLOW-UP ASSESSMENT IN THE NEONATAL PERIOD

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Subsequent assessment is usually done, in institutional delivery, on the first day of birth, i.e. within 24 hours and within the time of discharge. Daily clinical evaluation should be done, between first day examination and the day of discharge. Daily clinical evaluation should be done, between first day examination and the day of discharge. But daily detailed examination is not necessary because it may introduce infections. First day examinations should include the followings: General measurements: For full term infant average head circumference = 33 and 33.5cm. Chest circumference= 30.5-33cm. Head to heel length= 48-53 cm Body weight= 2700-4000g. Vital signs: Axillary temperature: 36.5 to 37.6 C( 97.7- 99.7F) Pulse: 120-140/mt Respirations: 30-60/mt Blood pressure: 65/41 mm of Hg

General appearance:
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Posture- complete flexion Behaviour- degree of alertness, drowsiness or irritability to be noted. PHYSICAL ASSESSMENT: Skin: Velvetty, smooth and puffy, color depending on the racial and family background. Head: Check the contour. Palpate fontanelles and sutures noting size , shape, molding, or abnormal closure.check for any cephal hematoma and caput succedaneum. Assess the degree of head control Eyes: Edematous lids, purulent discharge from eyes shortly after birth is abnormal. Sclera should be white and clear. Ears: Note the position , structure and auditory function. Top of the pinna should lie in horizontal plane to the outer canthus of eye. Observe startle reflex. Nose: Sneezing and thin white mucus common.

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Mouth and throat:

Size : small mouth found in trisomy 18 and 21; corners of mouth turn down (fish mouth) in fetal alcohol syndrome.

Mucous membranes should be pink. Palate examination (hard and soft palate )for closure. Size of tongue: in relation to mouth normally does not extend much past the margin of gums. Excessively large tongue seen in congenital anomalies, such as cretinism and trisomy 21.

Teeth: pre-deciduous teeth are found on rare occasions; if they interfere with feeding, they may be removed.

Epstein's pearls: small white nodules found on sides of hard palate (commonly mistaken for teeth); regress in a few weeks.

Frenulum linguae: thin ridge of tissue running from base of tongue along undersurface to tip of tongue, formerly believed to cause tongue-tie; no treatment necessary. True congenital ankyloglossia (tongue-tie) is rare.

Infections : thrush, caused by Candida albicans, may appear as white patches on tongue and/or insides of

cheeks that do not wash away with fluids; treated with nystatin suspension. Neck Examine the following:

Mobility : infant can move head from side to side; palpate for lymph nodes; palpate clavicle for fractures, especially after a difficult delivery.

Torticollis: appears as a spasmodic, one-sided contraction of neck muscles; generally from hematoma of sternocleidomastoid muscle; usually no treatment required.

Excessive skin folds may be associated with congenital abnormalities such as trisomy 21. Stiffness and hyperextension may be caused by trauma or infection. Clavicle for intactness. Observe for masses such as cystic hygroma which is soft and usually seen laterally or over the clavicle.
46

Chest

Circumference and symmetry : average circumference is 12 to 13 inches (30 to 33 cm), approximately 2 cm smaller than head circumference.

Breast.

Engorgement may occur at day 3 because of withdrawal of maternal hormones, especially estrogen; no treatment required. Regresses in 2 weeks.

Nipples and areola less formed and pronounced in preterm infants.

Respiratory System

Rate normally between 40 to 60 breaths/minute; influenced by sleep-wake status, when last fed, drugs taken by mother, and room temperature.

Rhythm respirations may be shallow with irregular rhythm. Breath sounds,determined by auscultation.

Cardiovascular System

Rate:normal between 110 to 160 bpm (80 to 110 normal with deep sleep); influenced by behavioral state, environmental temperature, medication; take apical count for 1 minute.

Rhythm:common to find periods of deceleration followed by periods of acceleration. Heart sounds,second sound higher in pitch and sharper than first; third and fourth sounds rarely heard; murmurs common, majority are transitory and benign.

Pulses,examine equality and strength of brachial, radial, pedal, and femoral pulses; lack of femoral pulses indicative of inadequate aortic blood flow.

Cyanosis,examine for cyanosis. Acrocyanosis of distal extremities is common; record location of any cyanosis, color changes with time, and when crying.

Blood pressure,neonates who weigh more than 3 kg have systolic blood pressure between 60 to 80 mm Hg; diastolic, between 35 and 55 mm Hg. Blood pressure is usually higher in the lower extremities than in the upper extremities. Blood pressure assessment may not be conducted routinely on healthy neonates. Measurement of blood pressure is essential

47

for infants who show signs of distress, are premature, or are suspected of having a cardiac anomaly. Abdomen

Shape,cylindrical, protrudes slightly, moves synchronously with chest in respiration. Distension may be caused by bowel obstruction, organ enlargement, or infection. Palpate abdomen for masses; gap between rectus muscles is common; palpate liver and spleen.

Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds occur an hour after delivery.

Kidneys palpate kidneys for size and shape. Umbilical cord

Normally contains two arteries, one vein; single artery sometimes associated with renal and other congenital abnormalities.

Signs of infection around insertion into abdominal wall-redness, discharge. Meconium staining,associated with intrauterine compromise or postmaturity. By 24 hours, becomes yellowish brown; dries and falls off in approximately 10 to 14 days.

Umbilical hernia,defect in abdominal wall.

Genitalia

Female

Labia majora cover labia minora and clitoris in full-term female infants. Hymenal tag (tissue) may protrude from vagina,regresses within several weeks. Vaginal discharge,white mucous discharge common; pink-tinged mucous discharge (pseudomenstruation) may be present because of the drop in maternal hormones; no treatment necessary.

48

Male

Full-term,testes in scrotal sac; scrotal sac appears markedly wrinkled due to rugae. Edema may be present in scrotal sac if the infant was born in breech presentation; a frank collection of fluid in the scrotal sac is a hydrocele,regresses in approximately a month.

Examine glans penis for urethral opening,normally central; opening ventral (hypospadias); opening dorsally (epispadias); abnormally adherent foreskin (phimosis).
o

Check for patent anus,infant should pass stool within 24 hours after delivery. If passed meconium in utero, patent anus has been established.

Back Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus; also for tufts of hair or skin disruptions that would indicate possible spina bifida. Examine anal area for anal opening, response of anal sphincter, fissures. Musculoskeletal System

Examine extremities for fractures, paralysis, range of motion, irregular position. Examine fingers and toes for number and separation: extra digits, polydactyly; fused digits, syndactyly.

Examine hips for dislocation,with the infant in supine position, flex knees and abduct hips to side and down to table surface; clicking sound indicates dislocation (Ortolani's sign).

Asymmetrical gluteal folds also indicate congenital hip dislocation. Examine feet for structural and positional deformities, ie, club foot (talipes equinovarus) or metatarsus adductus (inward turning of the foot).

Neurologic System

Neurologic mechanisms are immature anatomically and physiologically; as a result, uncoordinated movements, labile temperature regulation, and lack of control over musculature are characteristic of the infant.

49

Examine muscle tone, head control, and reflexes. Two types of reflexes are present in the neonate: Protective in nature (blink, cough, sneeze, gag),remain throughout life. Primitive in nature (rooting/sucking, moro, startle, tonic neck, stepping, and palmar/plantar grasp),either disappear within months or become highly developed and voluntary (sucking and grasping)

BEHAVIORAL ASSESSMENT Response to Stimulation Neonates exhibit predictable, directed responses in social interactions with nurturing adults or in response to attractive auditory or visual stimuli. Sleeping Pattern

Length of sleep cycles (REM, active and quiet sleep) changes with maturation of the central nervous system (CNS).

Quiet sleep should increase with time in relation to REM sleep. Neonates usually sleep 20 hours per day.

50

Feeding Pattern

Most neonates feeds 6 to 8 times per day with 2 to 4 hours between feedings; establish fairly regular feeding patterns in approximately 2 weeks.

Caloric requirements are high,110 to 130 calories/kg of body weight daily. Most digestive enzymes are present at birth. Imperfect control of cardiac and pyloric sphincters; immaturity results in regurgitation.

Pattern of Elimination Stool

o o

Meconium is usually passed in 24 hours. Passage of meconium (tarry green-black stools) continues for 48 hours, followed by transitional stools (combination of meconium and yellow or milk stools). Milk stools (yellow) are passed by day 5.

Neonate has up to six stools per day in the first weeks after birth.

Voiding
o o

Neonate voids within first 24 hours. After first few days, infant voids from 10 to 15 times per day.

Temperature Regulation

Infant's body responds readily to changes in environmental temperature. Heat loss at birth may occur through evaporation, convection, conduction, and radiation. Physiologic mechanisms to avoid heat loss include:
o o

Vasoconstriction. Nonshivering thermogenesis elicited by sympathetic nervous system in response to decreased temperature.

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REFLEXES OF NEWBORN

PRIMITIVE REFLEX Primitive reflexes are reflex actions originating in the central nervous system that are exhibited by normal infants but not neurologically intact adults, in response to particular stimuli. These reflexes disappear or are inhibited by the frontal lobes as a child moves through normal child development. These primitive reflexes are also called infantile, infant or newborn reflexes. ADAPTIVE VALUE OF REFLEXES Reflexes vary in utility. Some have a survival value. A perfect example would be the rooting reflex, which helps a breastfed infant find the mother's nipple. Babies display it only when hungry and touched by another person, not when they touch themselves. There are a few reflexes that probably helped babies survive during human evolutionary past like the Moro reflex. Other reflexes such as sucking and grabbing help establish gratifying interaction between parents and infants. They can encourage a parent to respond lovingly and feed more
52

competently. They can also help parents comfort their infant because they allow the baby to control distress and the amount of stimulation they receive. ROOTING REFLEX The rooting reflex is present at birth: it assists in breastfeeding, disappearing at around four months of age as it gradually comes under voluntary control. A newborn infant will turn his head toward anything that strokes his cheek or mouth, searching for the object by moving his head in steadily decreasing arcs until the object is found. After becoming used to responding in this way (if breastfed, approximately three weeks after birth), the infant will move directly to the object without searching.

Rooting reflex SUCKING REFLEX The sucking reflex is common to all mammals and is present at birth. It is linked with the rooting reflex and breastfeeding, and causes the child to instinctively suck at anything that touches the roof of their mouth and suddenly starts to suck simulating the way they naturally eat. There are two stages to the action: Expression: activated when the nipple is placed between a child's lips and touches their palate. They will instinctively press it between their tongue and palate to draw out the milk.
53

Milking: The tongue moves from areola to nipple, coaxing milk from the mother to be swallowed by the child. GRASP This reflex is shown by placing finger or an object into baby's open palm, which will cause a reflex grasp or grip. If it is tried to pull away, the grip will get even strong. The palmar and plantar grasp usually disappears by 5-6 months and 9-12 months respectively.

Palmar grasp reflex PLANTAR REFLEX A plantar reflex is a normal reflex that involves plantar flexion of the foot (toes move away from the shin, and curl down. BABINSKI REFLEX An infant demonstrating the Babinski reflex: he opens his mouth when pressure is applied to both palms (8 seconds). The Babinski reflex occurs in newborn babies, and describes varying responses to the application of pressure to both palms. Infants may display head flexion, head rotation or opening of the mouth, or a combination of these responses. Smaller, premature infants are more susceptible to the reflex. MORO REFLEX Also called the startle reflex, the Moro is usually triggered if baby is startled by a loud noise or if his head falls backward or quickly changes position. Baby's response to the moro will include spreading his arms and legs out widely and extending his neck. He will then
54

quickly bring his arms back together and cry. The moro reflex is usually present at birth and disappears by 3-6 months.

STARTLE REFLEX

The Moro reflex in a four-day-old infant: 1) the reflex is initiated by pulling the infant up from the floor and then releasing him; 2) he spreads his arms 3) he pulls his arms in; 4) he cries (10 seconds)

MORO REFLEX

55

WALKING/ STEPPING REFLEX The walking or stepping reflex is present at birth; though infants this young can not support their own weight, when the soles of their feet touch a flat surface they will attempt to 'walk' by placing one foot in front of the other. This reflex disappears at 6 weeks as an automatic response and reappears as a voluntary behavior at around eight months to a year old

WALKING/STEPPING REFLEX TONIC NECK REFLEX The tonic neck reflex, also known as asymmetric tonic neck reflex or 'fencing posture' is present at one month of age and disappears at around four months. When the child's head is turned to the side, the arm on that side will straighten and the opposite arm will bend (sometimes the motion will be very subtle or slight). According to researchers, the tonic neck reflex is a precursor to the hand/eye coordination of the infant. It also prepares the infant for voluntary reaching.

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TONIC NECK REFLEX Opposite reaction Tonic Neck Reflex A postural reaction, the asymmetric tonic neck reflex, or fencer response, is present at birth. To elicit this reflex, while your baby is lying on his back, turn his head to one side, which should cause the arm and leg on the side that he is looking toward to extend or straighten, while his other arm and leg will flex. This reflex usually disappears by 4-9 months. GALANT REFLEX If your baby is on his stomach and you stroke neck to the spinal cord (paravertebral area) on his middle to lower back, it will cause his back to curve towards the side that you are stroking. This reflex is present at birth and disappears by 3-6 months. If the reflex persists past six months of age, it is a sign of pathology. The reflex is named after the Russian neurologist Johann Susman Galant.

57

SWIMMING REFLEX An infant placed face down in a pool of water will begin to paddle and kick in a swimming motion. The reflex disappears between 46 months. Its survival function is to help the child stay alive if it is drowning so a caregiver has more time to save it. DOLLS EYE REFLEX Eyes open on coming to sitting (Like a Doll's) Head initially lags Baby uses shoulders to right head position PROTECTIVE REFLEX 1. Soft cloth is placed over the babies eyes and nose 2. Baby arches head and turns head side to side 3. Brings both hands to face to swipe cloth away CRAWLING REFLEX Newborn placed on abdomen Baby flexes legs under him and starts to craw PARACHUTE RESPONSE This is a protective response that protects infant if he falls. Beginning at about 5-6 months, if an infant falls, he will extend his arms to try and 'catch' himself. PROPPING Beginning at different ages, the propping responses help child learn to sit. The first is the anterior propping response, which begins at 4-5 months, and involves infant extending his arms when he is held in a sitting position, allowing him to assume a tripod position. Next, lateral propping, appearing at 6-7 months, causes him to extend his arm to the side if he is tilted.
58

Lastly, posterior propping, causing him to extend his arms backwards if he is titled backward. DAILY OBSERVATION OF NEONATES: Neonates should be observed daily during hospital stay. Detailed examination is not necessary but mother and baby should be approached two times daily and informations should be collected from the mother (or caretaker) about the feeding behavior, vomiting, passage of stool and urine, sleep and presence of any problems. The neonates should also be assessed for hypothermia, respiratory distress, jaundice and superficial infections like conjunctivitis, umbilical sepsis, oral thrush and skin infection. The neonates should be monitored for the danger signs. Presence of these features indicates special attention, reevaluation and early interventions. The danger signs are: Poor feeding, sucking and swallowing reflex. Cold to touch or having rise in body temperature Poor activity and poor response to stimulation Excessive crying and irritability Rapid respiration, more than 60 per minutes and presence of chest retractions Blue discoloration of lips or tongue (central cyanosis) Drooling of saliva or chocking during feeding or frothiness Labored respiration or absence of respiration Jaundice appears within 24 hours one extending to palms or soles No urine within 48 hours and no meconium within 24 hours Convulsions or abnormal movements Bleeding from any site Umbilical discharge Superficial infections (pyoderma, abscess, oral thrush, conjunctivitis) Diarrhea, vomiting and abdominal distension.

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NEONATAL INTENSIVE CARE UNIT GOALS AND OBJECTIVES

GOAL 1: Understand the pediatricians role in reducing morbidity in high risk pregnancies and complications of childbirth.

OBJECTIVES Describe general principles about: o Basic vital statistics that apply to newborns (neonatal, perinatal mortality,etc.) o Tests commonly used by obstetricians to measure fetal well-being. o Prenatal services available in ones region. o Prenatal visit in the pediatricians office. o Neonatal transport systems o Effective intervention programs for teens and other high risk mothers

For each of the following prenatal and perinatal complications o Describe the pediatricians role in assessment and management. o Recognize potential adverse outcomes for the fetus/neonate
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List of complications: o Maternal infections/exposure to infections during pregnancy o Fetal exposure to harmful substances (ETOH, TOB, street drugs, medications, environment toxins) o Maternal insulin-dependent diabetes and pregnancy-induced intolerance o Premature labor, premature ruptured membranes o Complications of anesthesia and common delivery practices (Cesaerean section, vacuum, forceps, epidural, induction of labor) o Fetal distress during delivery o Postpartum maternal fever/infection o History of maternal GBS colonization/treatment o Multiple gestation o Placental abnormalities o Pre-eclampsia, eclampsia PL 2,3l. Chorioamnionitis o Polyhydramnios o Oligohydramnios Discuss the pediatricians role in reducing fetal and neonatal morbidity/mortality ihis/her own community. glucose

GOAL 2: Understand how to resuscitate and stabilize a critically ill neonate.

OBJECTIVES Describe the steps in resuscitation and stabilization, including equipment needed. Demonstrate efficient and effective resuscitation in mock codes and under stress of actual codes. Formulate a differential diagnosis for serious symptoms presenting during transfer to the NICU or in the NICU immediately after resuscitation.

61

GOAL 3: Understand how to evaluate and manage common signs and symptoms of disease in high risk newborns.

OBJECTIVES For each of the signs and symptoms below: 1. Perform an appropriate assessment (H&P, Initial diagnostic studies). 2. Formulate a differential diagnosis with appropriate prioritization 3. Describe indications for admission or referral to Levels I, II, and III nurseries. 4. Describe stabilization procedures to prepare for transfer 5. Formulate and carry out a plan for continuing assessment and management.

List of Signs and Symptoms (NICU) General: Intrauterine growth failure Large for gestational age Hypothermia Hyperthermia, Prematurity Feeding problems Poor postnatal weight gain Lethargy/irritability/jitteriness, History of maternal infection or exposure, Dehydration.

Cardiorespiratory Respiratory distress Cyanosis Apnea Bradycardia

62

 Heart murmur Hypotension Hypotension Hypovolemia Poor pulses Shock.

Dermatologic: Common skin rashes/conditions, Birthmarks Hyper and hypopigmented lesions Discharge and/or inflammation of the umbilicus Proper skin care for premature infants Vesicles.

Gastro Intestinal/Surgical: Feeding intolerance Vomiting, Bloody stools Distended abdomen, Hepatosplenomegaly Abdominal mass Failure to pass stool Diarrhea.

Genetic/Metabolic: Metabolic derangements, Hypoglycemia Hypercalcemia Hypocalcemia, Hypokalemia

63

 Hyperkalemia Apparent congenital defect or dysmorphic syndrome.

Hematologic: Jaundice in a premature, term or seriously ill neonate, Petechiae Anemia, Polycythemia Abnormal bleeding, Thrombocytopenia Neutropenia.

Musculoskeletal Birth trauma related fractures and soft tissue injuries Dislocations Birth defects and deformities. Neurologic Hypotonia Hypertonia Seizures, Lethargy Early signs of neurologic impairment, Microcephaly, macrocephaly Spina bifida Birthtrauma related nerve damage.

Parental Stress/Dysfunction Poor attachment, Postpartum depression Anxiety disorders Teen parent
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Substance abuse Child abuse and Neglect.

Renal/Urologic Edema Decreased urine output Abnormal genitalia Renal mass Hematuria, Urinary retention Inguinal hernia.

Ophthalmologic Abnormal red reflex Eye anomaly

GOAL 4: Understand how to manage, under the supervision of a neonatologist, common diagnoses in infants in a Level II or III nursery.

OBJECTIVES For each of the following common diagnoses in the list below; be able to o Describe the pathophysiologic basis of the disease. o Describe the initial assessment plans. o Discuss key principles of the NICU management plan. o Explain when to use consultants. o Explain the role of the primary care provider.

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List of Common Diagnoses in this Setting (NICU) Pulmonary disorders: Hyaline membrane disease, transient tachypnea of the newborn, meconium aspiration, amniotic fluid or blood aspiration, persistent pulmonary hypertension, pneumonia, pneumothorax, bronchopulmonary dysplasia, atelectasis.

Cardiac conditions:

Congenital heart disease (cyanotic and acyanotic, obstructive lesions,

single ventricle), patent ductus arteriosus, congestive heart failure, SVT, complete heart block.

Genetic, endocrine disorders: Infant of diabetic mother, common chromosomal anomalies, congenital adrenal hyperplasia, hypo and hyperthyroidism.

GI/nutrition: Feeding plans and nutritional management of high risk neonates or those with special needs, breast feeding support for mothers and infants with special needs, hepatitis, gastrointestinal reflux, meconium plug, malrotation, Hirschprungs, necrotizing enterocolitis, short gut syndrome, gastroesophageal reflux.

Hematologic conditions: Indications for phototherapy, anemia, polycythemia, transfusion of blood products, exchange transfusions in the premature/term or ill neonate, erythroblastosis fetalis/hydrops fetalis, coagulopathy, hemophilia, Vitamin K prophylaxis/deficiency.

Infectious disease: Intrauterine viral infections, Group B Streptococcal infections, neonatal sepsis and meningitis, herpes simplex; infant of HIV infected mothers, neonatal hepatitis, syphilis; nosocomial infections in the NICU, central line infections, immunization of the premature neonate, isolation procedures for contagious diseases in mother/infant, indications for RSV prophylaxis.

Neurologic disorders: Hypoxic-ischemic encephalopathy, intraventricular hemorrhage, hearing loss in high risk newborns, drug withdrawal, seizures, hydrocephalus, spina bifida, CNS anomalies.

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Surgery: (assess and participate in management under supervision of or collaboration with pediatric surgeon) Necrotizing enterocolitis, short gut syndrome, intestinal perforation, intestinal obstruction, diaphragmatic hernia, malrotation, esophageal atresia and tracheoesophageal fistula, intestinal atresia, meconium ileus, meconium plug syndrome, gastroschisis, omphalocele, imperforate anus, pre-op and post-op care.

Eye disorders: retinopathy of prematurity, cataracts and eye anomalies

Miscellaneous: complications of umbilical catheterization

GOAL 5: Understand how to use and interpret laboratory and imaging studies unique to the NICU stetting.

OBJECTIVES Order and interpret laboratory and imaging studies appropriate for NICU patients. Explain indications, limitations, and gestational-age norms for the following which may have specific application to neonatal care: o Serologic and other studies for transplacental infections o Direct and indirect Coombs test o Neonatal drug screening o Neuro ultrasound o Abdominal x-rays for placement of umbilical catheter, bowel gas pattern, evidence of NEC o Chest x-rays for endotracheal tube placement, heart size and vascularity, deep line placement

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GOAL 6: Understand the application of the physiologic monitoring and special technology applied to the care of the fetus and newborn

OBJECTIVES For each of the following, which are commonlyused by pediatricians, discuss indications and limitations and demonstrate proper use/instruction in how to use: o Physiologic monitoring of temperature, pulse, respiration, blood pressure o Phototherapy o Pulse oximetry o Umbilical arterial and venous catheterization o Endotracheal intubation o Thoracentesis o Chest tube placement o Electric and manual breast pumps From each of the following techniques and procedures used by obstetricians,

perinatalologists, and neonatologists, describe key indications, limitations, normal and frequently encountered abnormal findings, and common complications for the fetus/infant: o Fetal ultrasound for size and anatomy o Fetal heart rate monitors o Scalp and cord blood sampling o Surfactant therapy o ECMO/Nitric oxide therapy o Amniocentesis o Biophysical profile/stress testing o Intrauterine transfusions/PUBS o Chorionic villus sampling o Exchange transfusion o Central hyperalimentation Discuss in general terms, home medical equipment and services needed for oxygen dependent and technology dependent graduates of the NICU.
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GOAL 7: Develop a logical and effective approach to the assessment and daily management of seriously ill neonates and their families, under the guidance of a neonatologist, using decisionmaking and problem solving skills.

OBJECTIVES Apply principles of decision-making and problem solving to care in the NICU. Seek information as needed and apply this knowledge appropriately using evidence baseproblem solving. Recognize the limits of ones own knowledge, skill, and tolerance of stress; know when to afor help, how to contact consultants and where to find basic information. Develop a comprehensive problem list with appropriate and accurate prioritization for action.

GOAL 8: Understand how to function effectively as part of an interdisciplinary team member in the NICU.

OBJECTIVES Communicate and work effectively with all members of the healthcare team (residents, attending, consultants, nurses, nurse specialists, lactation consultants, nutritionist, pharmacists, respiratory therapist, social workers, discharge coordinators, referring physicians and ancillary Staff). Communicate effectively with parents of critically ill patients and highly stressed families. Discuss role of primary care physician in the long term management of infants admitted to the NICU. Discuss the role of managed care case manager, work with these individuals to optimize healthcare outcomes.

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GOAL 9: Understand how to provide comprehensive and supportive care to the NICU infant and their family.

OBJECTIVES Serve effectively as an advocate and case manager for patients with multiple problems or chronic illnesses. Work with discharge coordinator to develop discharge plans which facilitate the familys transition to home care, including adequate follow-up and appropriate use of community services. Demonstrate sensitivity and skills in dealing with death and dying in the NICU setting. Consistently listen carefully to concerns of families and provide appropriate information and support. Provide counseling and support for breast feeding of premature and critically ill infants, including maintenance of mothers milk supply when the infant cannot suckle. Provide responsible communication with the neonates primary care physician during the hospital stay and in discharge planning. Identify problems and risk factors in the infant or family and make appropriate interventions and/or referrals.

GOAL 10: Become familiar with ethical and medical-legal consideration in the care of critically ill newborns.

OBJECTIVES Discuss concepts of futility, withdrawal and withholding care. Describe hospital policy on Allow Natural Death orders. Identify situations warranting consultation with the hospital ethics committee. Complete a death certificate appropriately.

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GOAL 11: Understand key aspects of cost control and mechanisms for payment in the NICU setting

OBJECTIVES Be sensitive to the burden of costs on families and refer for social services as indicated. Use consultants and other resources appropriately during NICU stay and in discharge planning. Demonstrate awareness of costs and cost control in NICU care. Explain principles of typical coverage by local insurance plan, Medical, and other state and federal subsidies for the care of high risk neonates.

GOAL 12:

Understand how to maintain accurate, timely and legally appropriate medical

records in the critical care setting of the NICU.

OBJECTIVES Ensure that initial history and physical examination records include appropriate history, exam appropriate for the infants condition, record of procedures in delivery room and since admission; problem list assessment and plan. Maintain daily timed notes, with updates as necessary, clearly documenting the patients progress and details of the on-going evaluation and plan. Ensure discharge summary is timely and concise, with clear documentation of discharge plans and follow up appointments.

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RESEARCH ARTICLE

1. HEARING SCREENING IN HIGH RISK NEWBORNS AND RESEARCH OF HIGH RISK FACTORS OF HEARING LOSS IN NEWBORNS. [Article in Chinese] Chen Y, Zhang Y, Guo Q, Ye C, Peng S. Source Department of Otolaryngology, Affiliated Hospital of Dali University, Dali, 671000, China. [email protected] Abstract OBJECTIVE: To identify the newborns who should receive hearing evaluation by hearing screening in high risk newborns; to find and confirm the high risk factors of hearing disorders in high risk newborns. METHOD: The first screening was performed by DPOAE. Newborns did not passed the first screening undertook second screening using DPOAE + ABR. and newborns did not passed the second screening received hearing evaluation. High risk factors of hearing loss were found by Logistic regression analysis.

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RESULT: Three hundred and twenty-seven cases were screened. The positive ratio in first screening was 37.0%. The positive ratio in second screening was 11.0%. Ten cases were diagnosed as hearing loss and the incidence of hearing loss was 3.39%. High risk factors of hearing loss were asphyxiation, very low born weight (<1,500 g) and head and neck abnormality. CONCLUSION: (1) DPOAE combined with ABR is credible and feasible in hearing screening of high risk newborns. (2) High risk factors of hearing loss were asphyxiation, very low born weight (<1,500 g) and head and neck abnormality in this study.

2. LONG TERM NEUROLOGICAL OUTCOME OF HIGH RISK INFANTS Authors: 1. Selzer, S C 2. Lindgren, S D 3. Blackman, J A

Abstract: Evaluated long-term neuropsychological outcome of 20 high risk infants with intracranial hemorrhage (ICH) during the neonatal period who appeared free of significant impairment through 30 months of age. This group was compared with a matched sample of 20 high risk infants without intracranial hemorrhage and a group of 70 children with no history of perinatal or chronic health problems. A comprehensive neuropsychological evaluation at age 5 revealed that the two high risk groups tended to perform at a lower level than the control group across most measures. However, the ICH group performed at a significantly lower level than the control group on measures of perceptual-motor skills and intermodal memory abilities while the high risk group without ICH did not. The implications of differences in level and pattern of performance are discussed along with the implications of the current findings for long-term functioning of high risk infants with ICH.

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SUMMARY
High-risk neonates may be defined as newborns, regardless of gestational age or birth weight, who have a greater than average chance of morbidity or mortality because of conditions or circumstances superimposed on the normal course of events associated with birth and adjustment to extrauterine existence. Identification of high-risk newborns may occur during any of the following stages: prenatal, natal, or postnatal. High-risk infants may be classified according to birth weight, gestational age, and morbidity factors. Meeting the high-risk infants nutritional needs requires specific knowledge of physiologic characteristics, the infants particular needs, and methods of feeding. Delayed development in high-risk neonates is a concern; developmental interventions are individualized to ameliorate the effects and increase infant well-being. Parental involvement in the care of high-risk infants is important, and nurses should encourage parent-infant relationships from birth to discharge. Prematurity accounts for the largest number of admissions to an NICU. Nurses play an important role in end-of-life care of the family of the dying infant.

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CONCLUSION
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 labor and birth. Some complications are unexpected and may occur without warning. Other times, there are certain risk factors that make problems more likely. Fortunately, advances in technology have helped improve the care of sick newborns. Under the care of specialized physicians and other healthcare providers, babies have much greater chances for surviving and getting better today than ever before.

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BIBLIOGRAPHY
Meharban Singh, Care of Newborn. 6th ed. Jaypee brothers medical publisher,pvt ltd ,New Delhi. D.K.Guha, Book of neonatology principles and practice ,2nd edition,Jaypee brothers medical publisher,pvt ltd ,New Delhi,page no-30-37. Hockenberry JM, Wilson D Wongs nursing care of infants and children. 8th ed. Missouri: Elsevier; 2007. p.271-80 Marlow RD Textbook of paediatric nursing. 6th ed. Pennsylvania: Elsevier; 2007.p.250-8. Pilliteri A Child health nursing. 1st ed. Philadelphia: Lippincott;1999.p.432-8. Parthasarathy A IAP textbook of paediatrics. 3rd ed. New Delhi: Jaypee;2006.p.442-6. Dutta AK, Sachdeva A Advances in paediatrics. 1st ed. New Delhi: Jaypee;2007.p.89-96. Ghai OP, Gupta P, Paul VK Ghai essential paediatrics. 6th ed. New Delhi: CBS; 2005.p.166-9. RESEARCH ARTICLE Chen Y, Zhang Y, Guo Q Hearing Screening In High Risk Newborns And Research Of High Risk Factors Of Hearing Loss In Newborns. Department of Otolaryngology, Affiliated Hospital of Dali University. 2010. Jan. Volume 19. 753-89. Selzer, S C, Lindgren, Blackman. Long Term Neurological Outcome Of High Risk Infants. Institute for Clinical and Translational Science: Elsevier publications.
http://www.icts.uiowa.edu/Loki/publications/browsePublication.jsp?id=1527677 ,

Sep 2,

2011.

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