2. Who Is an At-Risk Infant?
Risk of morbidity or mortality
Prenatal and intrapartal risk factors
Neonatal factors
Gestational age
Size
Anticipate complications
Assessments at birth - Apgar score
3. High Risk Infant
Congenital anomalies
Characteristics and potential problems
Preterm & postterm
Small for gestational age & large for gestational age
General concerns
Thermoregulation
Hypoglycemia
Respiratory distress and complications
Hyperbilirubinemia
Psychosocial neonate & family needs
4. Congenital Anomalies
Diaphragmatic Hernia
Abdominal contents herniate through diaphragm
Respirations are compromised
Signs
Barrel shape chest
Asymmetric chest expansion and absent
breath sounds on affected side
Respiratory distress and cyanosis
Scaphoid abdomen
5. Congenital Anomalies:
Diaphragmatic Hernia
Interventions
Oxygen
Respiratory support without over inflating
Gastric decompression
Head of bed elevated
Turn to affected side
Surgical repair
6. Congenital Anomalies:
Tracheo-Esophageal Fistula
Connection between the trachea and esophagus
Proximal esophagus ends in blind pouch and
distal esophagus joined to trachea
Signs
Increased oral secretions
Coughs and choking
Abdominal distention
Not able to pass nasal or oral gastric tube
Struggles with feeding
8. Congenital Anomalies:
Neurotubular Defects
Tissue protruding through vertebral column
Meningocele
Meningomyelocele
Impairment
Location and magnitude of defect determines
extent of neuro impairment
Sensory impairment follows motor, affects
bladder and anal sphincter, contractures and
deformities
9. Congenital Anomalies:
Neurotubular Defects
Intervention
Pregnancy -- Folic acid and Alpha fetal protein
Sterile, moist, normal saline dressing
Prevent infection
Decrease trauma
Monitor for changes in fluid and heat loss
Surgical repair, keep prone with legs flexed,
no diaper over incision
Long term: hydrocephalus, wheelchair,
braces, catheterization
10. Congenital Anomalies:
Gastrocele and Omphalocele
Gastroschisis
Abdominal contents protrude through wall
No sac covering intestines
Omphalocele
Abdominal contents protrude into umbilical cord
Covered by translucent sac
Associated with other anomalies
11. Congenital Anomalies:
Gastrocele and Omphalocele
Interventions
Warm, moist, sterile dressing and plastic
wrap
Maintain hydration and temperature
Position supine or side
Gastric decompression
Surgical repair
Complications
12. Congenital Anomalies:
Choanal Atresia
Occlusion at nasopharnyx
Signs
Snorting respirations
Difficulty breathing with feedings
Cyanosis
Interventions
Assess patency of nares
Maintain airway with oral airway
Position with head of bed elevated
13. Congenital Anomalies:
Cleft Lip and Palate
Fissure involving nares, nasal septum, or
connecting oral and nasal cavity
Intervention
Feedings with special nipples
Feed upright and burp frequently
Prevent aspiration
Clean mouth after feedings
14. Congenital Anomalies:
Heart Defects
Signs
Cyanosis
Heart murmur
Heart failure
Most common defects
Patent ductus arteriosus
Ventricular septal defect- most common in Children
Coarctation of the aorta
Hypoplastic left heart
Tetralogy of Fallot
Transposition of the great vessels
19. Inborn Error of Metabolism:
Phenyleketonuria (PKU)
Condition affects protein metabolism
No enzyme to convert phenylalanine to
tyrosine
Affects development of brain and CNS
Mental retardation if untreated
CNS damage minimized if treatment before
age 3 months
20. Inborn Error of Metabolism:
Phenyleketonuria (PKU)
Assessment
Positive Guthrie test – 24 hrs after feedings
Failure to thrive - Microcephaly
Vomiting - Hyperactivity
Skin lesions - Irritability
Repetitive motions
Seizures and tremors
Musty odor from skin and urine
Intervention
Low-phenylalanine formula
Teach parents allowed foods in the diet
21. Inborn Error of Metabolism:
Congenital Hypothyroidism
Enzymatic defect, lack of idodine in maternal
diet, or maternal drugs can depress thyroid
tissue
Causes growth and mental retardation
Assessment
Large tongue = Prolonged jaundice
Umbilical hernia = Poor feeding
Mottled skin = Low-pitch cry
Large fontanelles = Poor weight gain
Hypotonia = Delayed development
Intervention: Monitor thyroid medication
22. Identification of At-Risk Newborns
Gestational age
Preterm
Post-term
Size of neonate
Small for gestational age
Large for gestational age
23. Large for Gestational Age
Birth weight at or above the 90th percentile
Etiology
Large parents
Multiparous women
Males larger than female
Assessment findings
Poor muscle tone and motor skills
Difficult to arouse and maintain an alert state
24. Large for Gestational Age
Complications
Birth trauma – ceohalopelvic disproportion
Asphyxia
Meconium aspiration
Polycythemia
Hypoglycemia
25. Infant of Diabetic Mother
Severe diabetes associated with vascular
complications may have small babies
Mothers with classes A and C may have LGA
High glucose stimulates fetal insulin increase
Complications
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia
Birth trauma
26. Infant of a Diabetic Mother
Complications
Polycythemia
Respiratory distress syndrome
Congenital birth defects
Interventions
Test blood glucose
Cord blood; q hr X 4; q 4hr for 24 hrs
If blood glucose is < 40 mg/dl
Feeding
IV fluid of 10% dextrose water
27. Small for Gestational Age
Birth weight at or below the 10th percentile
Intrauterine growth retardation
Deficiency of nutrients through the placenta
Poor nutrition
Smoking or drug use
Pregnancy induced hypertension
Advanced diabetes
Intrauterine infection
28. Small for Gestational Age
Physical characteristics
Decreased subcutaneous tissue
Loose skin
Thin/dry umbilical cord
Alert for size
Dubowitz changes
Problems
Hypothermia
Hypoglycemia
Asphyxia
Meconium aspiration
29. Small for Gestational Age
Problems
Hypocalcemia
Feeding difficulties
Polycythemia
Interventions
Support respirations
Provide neutral thermal environment
Provide appropriate nutrition and hydration
Monitor blood glucose levels
Cluster care
Provide skin care
30. Post-term Infant
Infant born after 42 weeks gestation
Most continue to be well nourished
Postmaturity syndrome
Calcium deposits decrease placenta
function
Results in lack of oxygen and nutrients
Physical characteristics
Absent vernix and decreased lanugo
Dry, cracked, parchment-like skin, peeling
Hard, long nails
Abundant scalp hair
32. Premature Infant
Born before the 37th week gestation
Physical characteristics
Skin is thin, smooth, shiny, with visible veins
Minimal subcuatneous fat deposits
Lanugo over body
Minimal sole and palm creases
Large head
Ears have soft cartilage
Genitals
Posture is extended
Reflexes absent or weak -- suck, gag
36. Apnea and Bradycardia
Interventions
Tactile stimulation
Suction airway
Provide oxygen
Provide mechanical ventilation
Correct underlying cause
Administer CNS stimulants
Caffeine or theophylline
37. Intraventricular hemorrhage
Hemorrhage in the ventricles of the brain
May cause motor deficits
Hydrocephalus
Sight and hearing loss
Causes
Capillary walls vulnerable to hypoxic events
Hypoxia & high CO2 dilates cerebral vessels
Changes in intravascular pressure
38. Intraventricular hemorrhage
Signs
May be no signs
Bulging fontanel
Signs of intracranial pressure
Interventions
Keep cerebral blood flow constant
Prevent hypoxia
Prevent increased blood pressure
Elevate head of bed
39. Anemia
Causes
Iron stored late
Short life of RBC
Blood drawing
Hemorrhage
Interventions
Transfuse Packed red blood cells
Iron suppliments and erythopoientin
Signs
Pallor
Tachypnea
Dyspnea
Tachycardia
Activity intolerance
Feeding difficulty
40. Retinopathy of Prematurity
Progressive disorder of retina vessels
Scar tissue and retina detachment
Causes
Fragile retinal vessels
Fluctuating oxygen administration levels
lead to rapid vasodilation and
vasoconstriction
Also occurs with hypoxemia,
intraventricular hemorrhage, infection,
acidosis, exposure to bright lights
41. Retinopathy of Prematurity
Interventions
Decrease intracranial pressure
Careful O2 administration
Decrease lighting in NICU
Eye exams
May regress spontaneously
Laser/cryosurgery
Vitamin E
42. Necrotizing entercolitis
Cause
Bowel eschemia during hypoxia
Gas forming bacteria invade damaged cells
of intestinal wall
Cells rupture causing air in surface of
bowel
Damages bowel wall and causes bleeding
Milk in bowel provides rich media for
bacteria growth
43. Necrotizing entercolitis
Abdominal signs
Pneumotosis in bowel wall
Free air in abdomen if perforated
Distended and shiny abdomen
Gastric retention
Blood in stools
No bowel sounds
Signs of sepsis
44. Necrotizing entercolitis
Interventions
NPO
Nasal gastric tube for decompression
X-rays to follow deterioration of bowel
Antibiotics
Surgery – resection of damaged portion
Monitor for abdomen distension
Hematest stools
Long-term IV therapy
Decrease O2 consumption
45. Nutrition for the Preterm
Inability to nipple feed until 35-36 wks
Gag reflex
Suck/swallow/breathe coordination
Tires easily and worsens respiratory distress
Require different composition of formula
Increased metabolic rate
Difficulty consuming calories
Low iron and glycogen stores
Equipment
46. Nutrition for the Preterm
IV total parenteral nutrition and lipids
Gavage feedings
Calorie requirement
Fluid requirement
High insensible water loss
Urine output
Signs of feeding intolerance