1.
High Risk Neonates and
Infants


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

7.
Congenital Anomalies:
Tracheo-Esophageal Fistula
 Interventions
 Withhold feedings
 Elevate head of bed
 Suction to blind pouch to decrease
aspiration
 Surgery

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

15.
Substance-abusing Mother:
Fetal Alcohol Syndrome
 Facial abnormalities
 Behaviors
 Difficulty establishing respirations
 Sleeplessness - Jittery
 Hyperalert states - Hyper reflexes
 Inconsolable crying - Poor sucking
 Irritability - Lethargy

16.
Substance-abusing Mother:
Fetal Alcohol Syndrome
 Long-term complications
 Hypotonic and poor coordination
 Mental retardation or normal intelligence
 Speech and learning disabilities
 Hyperactivity and impulsivity
 Growth retardation
 Intervention
 Treat respiratory distress
 Reduce environmental stimulation
 Extra feeding time

17.
Substance-abusing Mother:
Drug Dependence
 Pregnant woman increased risk of
 Abruptio placentae, abortion, preterm
labor, precipitous labor
 Neonate increased risk of
 Intrauterine asphyxia
 Respiratory problems
 Urogenital malformation
 Cerebrovascular complications
 Low birth weight and head circumference
 Drug withdrawal

18.
Substance-abusing Mother:
Drug Dependence
 Key assessment findings
 Tachypnea - Sensitive to stimuli
 High-pitched cry - Low birth weight
 Jitteriness - Hyperactive Moro reflex
 Poor sleeping - Increased reflexes
 Irritability - Diarrhea & vomiting
 Interventions
 Swaddling - Calm environment
 Frequent feeding - Medication
 Promote bonding

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

31.
Post-term Infant
 Physical characteristics
 Loose skin
 Decreased subcutaneous fat
 Problems
 Hypothermia
 Hypoglycemia
 Asphyxia
 Meconium aspiration
 Polycythemia
 Interventions
 Supportive

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

33.
Premature Infant
 Problems
 Hypothermia
 Hypoglycemia
 Respiratory distress syndrome
 Apnea and bradycardia
 Patent ductus arteriosus
 Hyperbilirubinemia
 Anemia
 Intraventricular hemorrhage
 Retinopathy of prematurity
 Necrotizing entercolitis

34.
Apnea & Bradycardia
 Bradycardia: heart rate less than 100 bpm
 Apnea: not breathing for > 15 to20 seconds
 Causes of apnea
 Obstructed airway
 Hypothermia or hyperthermia
 Hypoglycemia
 Sepsis
 Respiratory distress

35.
Apnea and Bradycardia
 Causes of apnea
 Anemia
 Hypercapnea
 Sepsis
 Hypocalcemia
 Seizure
 Vagal response
 Dehydration
 CNS depression
 Intraventricular hemorrhage

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