Chapter 29 The High-Risk Newborn: Problems Related to Gestational Age and Development

LPI Feedings

- have immature suck and swallow reflexes, have shorter awake periods, and fall asleep during feedings before they have fed adequately, or they may sleep through feedings -difficulty with latch when breastfeeding. -low tone and weak suck may decrease the amount of milk they obtain -increased caloric need and should be fed every 2 to 3 hours.

Positioning the Infant with Respiratory Problems

- side-lying and prone positions facilitate drainage of respiratory secretions and regurgitated feedings. - In the preterm infant, however, the prone position increases oxygenation and enhances respiratory control, improves lung mechanics and volume, and reduces energy expenditure -Supine positioning for sleep is begun when the infant can tolerate it and before discharge so the infant can become accustomed to sleeping on the back before going home.

LPI Thermoregulation

- temperature checked only once a shift. To prevent unrecognized cold stress, the temperature of the LPI should be checked every 3 to 4 hours, depending on need and agency policy -Kangaroo care (KC), (a method of providing skin-to-skin contact between infants and their parents), a radiant warmer, or an incubator may be used if the infant cannot maintain normal temperature.

Gavage feedings

-A small, soft catheter is inserted through the nose or mouth to provide intermittent or continuous feedings.

Interventions.

-Administering Parenteral Nutrition -Administering Enteral Feedings -Administering Gavage Feedings -Administering Oral Feedings -Facilitating Breastfeeding -Making Ongoing Assessments

Problems with Pain

-Caregivers once thought that newborns, particularly preterm infants, were neurologically too immature to feel pain. It is now recognized preterm infants do feel pain, and pain stimuli cause physiologic and behavioral changes in infants.

Interventions for pain

-Containment simulates the enclosed space of the uterus and is comforting to infants. It involves keeping the extremities in a flexed position and midline by swaddling, positioning devices, or the nurse's hands. At least one of the infant's hands should be near the mouth for sucking. - should be allowed to rest before and after procedures. -pacifier for nonnutritive sucking. -Sucrose placed on the pacifier or given by mouth 2 to 3 minutes before a painful stimulus increases pain relief. - Talking softly, holding, rocking, or prone positioning are other methods of pain relief that may be used alone or with sucrose. -may be combined such as skin-to-skin contact with a sucrose-dipped pacifier

ROP Management

-Infants born at 30 weeks of gestation or less, those weighing 1500 g or less at birth, and infants with a birthweight of 1500 to 2000 g who were unstable should be screened for changes of the eyes 4 weeks after birth or at 31 weeks gestational age. Laser surgery to destroy abnormal blood vessels is the current treatment of choice. Cryosurgery or reattachment of a detached retina also may be necessary.

Late Preterm Infants

-Infants born between 34 0/7 and 36 6/7 weeks of gestation -physiologically and metabolically immature and have a higher mortality and morbidity rate than full-term infants. -should not be discharged before 48 hours of age. -should ensure that infants have fed successfully and have had normal vital signs for at least 24 hours before discharge.

Intraventricular hemorrhage (IVH) is also called periventricular-intraventricular hemorrhage or germinal matrix hemorrhage.

-It is bleeding around and into the ventricles of the brain. Approximately 30% of preterm infants weighing less than 1500 g develop IVH -The first few days of life are the most common times for hemorrhage to occur. -It may also occur in term infants from asphyxia or trauma

Interventions...

-Making Advance Preparations -Assisting Parents at Birth -Supporting Parents during Early Visits -Providing Information -Instituting Kangaroo Care (KC) -Facilitating Interaction -Increasing Parental Decision Making -Alleviating Concerns -Helping with Ongoing Problems -Preparing for Discharge

RDS Management

-Surfactant replacement therapy may be instilled into the infant's trachea immediately after birth or as soon as signs of RDS become apparent. -oxygen, CPAP or mechanical ventilation, inhaled nitric oxide therapy, correction of the acidosis, IV fluids, and care of other complications. -Maintenance of thermoregulation is essential.

Total parenteral nutrition

-the IV infusion of solutions containing the major nutrients needed for metabolism and growth. It provides calories, amino acids, fatty acids, vitamins, and minerals in amounts adapted to the needs of infants. It is continued, in decreasing amounts, until the infant is able to tolerate full enteral feedings.

Postterm infants

-those who are born after the 42nd week of gestation. Their longer-than-normal gestation places them at risk for a number of complications.

Necrotizing Enterocolitis (NEC)

- a serious inflammatory condition of the intestinal tract that may lead to necrosis of the intestinal mucosa. It occurs in 1% to 5% of infants admitted to NICUs and 6% to 10% of infants with birthweights under 1500 g -The mortality rate is 10% to 30% -The ileum and proximal colon are the areas most often affected. -immaturity of the intestines is a major factor.

SS Of RDS

- begin during the first hours after birth and include tachypnea, nasal flaring, retractions, and cyanosis. Grunting on expiration is characteristic and signifies physiologic efforts to maintain lung expansion. Breath sounds may be decreased, and rales may be present. Acidosis develops as a result of hypoxemia. -Chest radiographs show the "ground glass" reticulogranular appearance

Interventions

- focused on providing developmentally supportive nursing care that meets the preterm infant's ability to tolerate stimulation. -Scheduling Care-schedule periods of undisturbed rest -Reducing Stimuli-Keep noise as low as possible -Promoting rest-"Quite Times" , Only emergency procedures take place, At least an hour to allow complete sleep cycle -Promoting Motor Development-Reposition the infant every 2 to 3 hours or when other care is provided. Change the position slowly as it may be stressful. -Individualizing Care-Consistent care from the same person -Communicating Infants' Needs- nursing care plan, Kardex, and shift reports to inform other caregivers of techniques that are especially effective for certain infants. Explain all techniques to parents so they can participate in care appropriately.

Temperatures

-The abdominal skin temperature is usually maintained at 36° C to 36.5° C (96.8° F to 97.7° F). The infant's temperature should be recorded every 30 to 60 minutes initially and every 1 to 3 hours when the infant is stable -The axillary temperature for a preterm infant should remain between 36.3° C and 36.9° C (97.3° F and 98.4° F) slightly lower than the temperature in a full-term infant

Problems with Fluid and Electrolyte Balance

-The rapid respiratory rate and the use of oxygen increases fluid loss from the lungs. Their thin skin has little protective subcutaneous white fat and is more permeable than the skin of term infants. The large surface area, in proportion to body weight, and lack of flexion further increase transepidermal water losses. Radiant warmers heighten insensible water losses by 40% to 50%, compared with water loss in an incubator. Heat from phototherapy lights causes more fluid loss through the skin. -The ability of the kidneys to concentrate or dilute urine is poor, causing a fragile balance between dehydration and overhydration. - Normal urinary output is 2 to 5 mL/kg per hour for preterm infants - Preterm infants need higher intakes of sodium because the kidneys do not reabsorb it well.

fetal growth restriction (FGR).

-They have failed to grow in the uterus as expected

Problems with Thermoregulation

-They have thin skin with blood vessels near the surface and little subcutaneous (white) fat for insulation. Less brown fat is present for nonshivering thermogenesis. Preterm infants' body surface area in proportion to their body mass is five times that of adults - The temperature control center of the brain of preterm infants is less mature and may be further impaired by asphyxia.

Characteristics of Small-for-Gestational-Age (SGA) Infants

-Variation occurs because growth restriction affects the weight first. If it continues, the length and then the head size will eventually be affected. -Symmetric growth restriction -involves the whole body and may be caused by congenital anomalies, genetic disorders, exposure to infections or drugs early in pregnancy, or normal genetic predisposition. -appears normally developed for size. -Asymmetric growth restriction- caused by conditions that begin in the third trimester that interfere with uteroplacental function or nutrition -the head is normal in size but seems large for the rest of the body. -Brain growth is normal, but the liver, spleen, thymus, adrenals, and placenta are smaller than normal -The infant appears thin and wasted. The dry, loose skin has longitudinal thigh creases from loss of subcutaneous fat, and a sunken abdomen. The infant has a thin cord, and the facial appearance of being elderly. The anterior fontanel may be large with wide or overlapping cranial sutures

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease

-a chronic condition occurring most often in infants weighing less than 1000 g born at 28 weeks of gestation or less

Respiratory Distress Syndrome (RDS)

-a condition caused by insufficient surfactant in the lungs. It occurs most frequently in preterm infants and increases as gestational age decreases. It also occurs when there has been asphyxia, cesarean delivery, multiple births, male infants, cold stress, and maternal diabetes, because these conditions interfere with surfactant production.

NEC Management

-antibiotics, discontinuation of oral feedings, gastric suction, IV fluids, and use of parenteral nutrition to rest the intestines. Peritoneal drainage may be performed. Surgery is necessary for perforation or continued lack of improvement. The necrotic area is removed, and an ostomy is performed.

Apneic spells

-are a lack of breathing lasting more than 20 seconds, or accompanied by cyanosis, pallor, bradycardia, or hypotonia -common in preterm infants, increasing in incidence with lower gestational age. -without an identified cause in a preterm infant is called idiopathic apnea or apnea of prematurity and generally improves as the infant matures. -may require gentle tactile stimulation, medications, or continuous positive airway pressure

Infants needing many procedures

-are usually placed under an open radiant warmer to make it easier to see them and work with equipment. -Doors near the warmer should be closed and traffic kept to a minimum to decrease convective heat loss. The infant should receive only warmed oxygen, because thermal receptors in the face are very sensitive to cold. Cold oxygen could quickly lead to cold stress.

Preventing preterm birth

-best accomplished by providing adequate prenatal care for every pregnant woman to identify and treat risk factors as early as possible. Teaching women to recognize signs of preterm labor will help them seek care when stopping labor is still a possibility

LPIs are at risk for hypoglycemia

-blood glucose level measurements should be performed according to hospital protocol, especially during the first 24 hours.

Preterm infants (also called premature infants)

-born before the beginning of the 38th week of gestation.

SS of IVH

-determined by the severity of the hemorrhage. Infants may have no signs or may show lethargy, poor muscle tone, deterioration of respiratory status with cyanosis or apnea, drop in hematocrit level, acidosis, hyperglycemia, decreased reflexes, tense fontanel, and seizures. Mild aberrations of eye position or movement may occur. Signs may be few and subtle.

SS of postmaturity syndrome

-dry, cracked, peeling skin and no vernix. -apprehensive look associated with hypoxia -thin with loose skin and little subcutaneous fat. There is little or no vernix caseosa, but the infant generally has abundant hair on the head and long nails. -If meconium was present in the amniotic fluid for some time, the cord, skin, and nails may be stained. Postterm infants should be assessed for hypoglycemia because of rapid use of glycogen stores. If loss of subcutaneous fat has occurred, the infant may have a low temperature.

Enteral feedings

-feeding into the gastrointestinal tract, orally or by feeding tube

SS of NEC

-feeding intolerance, increased abdominal girth caused by distention, increased gastric residuals, decreased bowel sounds, visible loops of bowel, vomiting, abdominal tenderness, erythema of the intestinal wall, blood in the stools, and signs of infection. Respiratory difficulty may occur because of pressure from the distended abdomen on the diaphragm. Apnea, bradycardia, temperature instability, lethargy, hypotension, and shock also may be present.

Problems with the skin in preterm infants

-fragile, permeable, easily damaged skin. They often have endotracheal tubes, IV lines, electrodes, and other equipment that must be maintained in place, but standard adhesive tape can be very damaging to the skin, especially during removal. Preparations used to disinfect the skin before invasive procedures can be harmful to fragile skin and may be absorbed.

Preterm infants Appearance

-frail and weak, and they have less developed flexor muscles and muscle tone compared to full-term infants. Their extremities are limp, and infants typically lie in an extended position -head appears large in comparison with the rest of the body. lack subcutaneous or white fat, which makes their thin skin appear red and translucent, with blood vessels clearly visible. -The nipples and areola may be barely perceptible, but vernix caseosa and lanugo may be abundant. -Plantar creases are absent in infants of less than 32 weeks of gestation -clitoris and labia minora appear large and are not covered by the small, separated labia majora.

fetal growth restriction (FGR).

-full term and have failed to grow normally while in the uterus

Preterm infants Behavior

-have little excess energy for maintaining muscle tone. They are easily exhausted from noise and routine activities. -Their responses are varied, including lowered oxygenation levels and stress-related behavior changes. -The cry may be feeble.

postmaturity syndrome or dysmaturity syndrome

-hypoxia and malnourishment in the fetus -placental functioning decreases when pregnancy is prolonged -If placental insufficiency is present, decreased amniotic fluid volume (oligohydramnios) and umbilical cord compression may occur. The fetus may not receive the appropriate amount of oxygen and nutrients and may be small for gestational age.

Problems with Infection

-incidence of infection in preterm LBW infants is 3 to 10 times greater than that in full-term normal-birth-weight newborns. Many preterm infants have one or more episodes of sepsis during their hospital stays. Factors contributing to the high rate of infection include exposure to maternal infection, lack of transfer of immunoglobulin G (IgG) from the mother during the third trimester, and immature immune response to infection.

Large-for-gestational-age (LGA)

-infants are those who are greater than the 90th percentile for gestational age on intrauterine growth charts. They may have macrosomia (weigh more than 4000 g [8 lb, 13 oz]) and are usually born at term, although they may be preterm or postterm. The preterm LGA infant may be mistaken for full term but has the same problems as other preterm infants. - born to multiparas, large parents, mothers who are obese, and members of certain ethnic groups known to have large infants. Diabetes in the mother may also cause increased size, as may erythroblastosis fetalis - Shoulder dystocia may occur because the shoulders are too large to fit through the pelvis. Fractures of the clavicle or skull, damage to the brachial plexus or facial nerve, cephalhematoma, and bruising occur more often in these infants -Therapeutic management is based on identification of increased size during pregnancy by measurements of fundal height and ultrasound examination.

Small-for-gestational-age (SGA)

-infants are those who fall below the 10th percentile in size on growth charts. -The terms SGA and FGR are often used interchangeably -infants may be preterm, full-term, or postterm.

Extremely low-birth-weight (ELBW)

-infants weigh 1000 g (2 lb, 3 oz) or less at birth.

Very-low-birth-weight (VLBW)

-infants weigh 1500 g (3 lb, 5 oz) or less at birth.

Periodic breathing

-is the cessation of breathing for 5 to 10 seconds without other changes. -It may be followed by rapid respirations for 10 to 15 seconds.

Problems with Respiration

-major concern because preterm newborns have immature lungs. The presence of surfactant in adequate amounts is of primary importance. Surfactant reduces surface tension in the alveoli and prevents their collapse with expiration. It allows the lungs to inflate with lower negative pressure, decreasing the work of breathing. Infants born before surfactant production is adequate develop respiratory distress syndrome (RDS) -have a poorly developed cough reflex and narrow respiratory passages, which increase the risk for respiratory difficulty.

Grunting

-may be an early sign of RDS. It closes the glottis and increases the pressure within the alveoli, keeping the alveoli partially open during expiration and increasing the amount of oxygen absorbed.

Retinopathy of prematurity (ROP)

-may result in visual impairment or blindness in preterm infants. It occurs most often in preterm infants weighing less than 1000 g and less than 29 weeks of gestational age. - results from injury to retinal blood vessels. - high levels of oxygen.

Complications of heat loss

-more likely in the preterm infant than in the full-term infant. -include hypoglycemia, metabolic acidosis, pulmonary vasoconstriction, impaired surfactant production, and hyperbilirubinemia. In addition, calories used for heat production are unavailable for growth and weight gain

low birth weight (LBW)

-refers to infants weighing 2500 g (5 lb, 8 oz) or less at birth.

Late Preterm Infants are at risk for

-respiratory disorders -problems with temperature maintenance -hypoglycemia -hyperbilirubinemia -feeding difficulties -acidosis -sepsis because of their immaturity -long-term neurodevelopmental disorders as well as cognitive and behavioral problems -more likely to be admitted to NICU after birth and are at increased risk for rehospitalization after discharge.

Disorders related to short gestation and low birth weight

-second leading cause of infant mortality, surpassed only by those from congenital anomalies

Adhesives and preterm infants skin

-should be used as little as possible. Commercial devices are available to secure tubes and catheters. Backing tape with cotton, waiting more than 24 hours to remove it, and using gauze wraps instead of tape decrease skin damage. Pectin or hydrocolloid barriers, transparent semipermeable dressings, hydrogel or silicone-based adhesive products, and barrier films are less traumatic to the skin and may be used to attach devices

IVH Management

-ultrasonography is often performed at 7 days of age on preterm infants at risk -supportive and focuses on maintaining respiratory function and dealing with other complications. Hydrocephalus may develop from blockage of cerebrospinal fluid flow. A ventriculoperitoneal shunt (catheter leading from the ventricles of the brain to the peritoneal cavity) may be necessary to drain the fluid.

AAP and ACOG (2007) recommend the following in determining the time of discharge:

1.Signs of readiness for discharge include a sustained pattern of weight gain, adequate maintenance of body temperature in an open bed, feeding without cardiorespiratory compromise, and stable cardiorespiratory function. 2.Appropriate immunizations should have been given, metabolic screening performed, assessment of hearing, the eyes, hematologic status, and nutritional risks performed, and appropriate treatment plans completed before discharge. 3.The family and home should have been evaluated. The family must have at least two members who demonstrate the ability to feed and provide all needed care, perform cardiopulmonary resuscitation, give medications, operate equipment, and show understanding of signs of problems and what to do about them. 4.A primary care physician and other appropriate follow-up care have been arranged.

•Risk for Disorganized Infant Behavior related to stress from an overstimulating environment.

Expected Outcomes- The infant will show decreasing signs of overstimulation during routine activity, as evidenced by fewer respiratory and behavioral changes during handling and increased periods of relaxed behavior or sleep

•Risk for Imbalanced Nutrition: Less Than Body Requirements related to uncoordinated suck and swallow and fatigue during feedings.

Expected Outcomes- The infant will take in adequate amounts of breast milk or formula to meet nutrient needs for age and weight and will gain 15 to 20 g/kg/day.

•Risk for Impaired Attachment related to separation of parents from infant and lack of understanding about the preterm infant's condition and characteristics.

Expected Outcomes- The parents will demonstrate bonding behaviors, including visiting or calling frequently and interacting as appropriate for the infant's condition throughout the hospital stay. The parents will verbalize understanding of the preterm infant's condition and characteristics within 2 days and will express gradually increasing comfort in participating in infant care throughout the hospital stay

Signs of Inadequate Thermoregulation

• Axillary temperature <36.3° C to >36.9° C (<97.3° F to >98.4° F) • Abdominal skin temperature <36° C to >36.5° C (<96.8° F to >97.7° F) • Poor feeding or feeding intolerance • Irritability followed by lethargy • Weak cry or suck • Decreased muscle tone • Skin pale, cool to touch, mottled or acrocyanotic • Hypoglycemia • Respiratory distress • Poor weight gain if chronic

Signs of Overstimulation in Preterm Infants- Oxygenation Changes

• Blood pressure, pulse, and respiratory instability • Cyanosis, pallor, or mottling • Flaring nares • Decreased oxygen saturation levels • Sneezing, coughing

INTRODUCING PARENTS TO THE NEONATAL INTENSIVE CARE UNIT SETTING When Parents Visit the NICU

• Help parents perform thorough handwashing while explaining the importance. • Stay with the parents during their visit. Having a familiar person nearby will help them feel more comfortable while they adjust to this unfamiliar environment. • Introduce them to the infant's nurse. Ask the nurse to explain some of the care being provided for the infant. • Give parents written information about the NICU so that they can take it home to read later. This should include visiting hours, telephone updates, available classes on preterm infant care, and support groups. • Tell the parents that they will receive instruction on how to care for their infant in time. Encourage them to visit the infant as much as they can. Emphasize how important they are to their infant. • Offer realistic encouragement based on the infant's condition. • Provide an opportunity for the parents to express their concerns and feelings and to ask questions.

INTRODUCING PARENTS TO THE NEONATAL INTENSIVE CARE UNIT SETTING Before Parents Visit the Neonatal Intensive Care Unit (NICU)

• If possible, provide parents with a tour of the NICU before the birth. • If a tour is not possible, describe the NICU environment. Include alarm noise, staff activity, the number of people and sick infants. • Describe the equipment. Include ventilators, intravenous (IV) lines, feeding tubes, and monitors. Explain how they look and how they are attached to the infant. Keep explanations simple, without technical details. • Show parents photographs of the infant. These help prepare them but are not as overwhelming as seeing the infant in person. • Describe the infant. Include the size, lack of fat, breathing, and weak cry. Explain that no sound of crying can be heard if the infant is intubated. Include some personal aspects: "He's a real fighter" or "She makes the funniest faces during her feedings."

Adverse Signs during Nipple Feedings

• Increased or decreased heart rate • Increased or decreased respiratory rate • Markedly decreased oxygen saturation level • Apnea • Cyanosis, pallor • Coughing, choking • Gagging, spitting up • Drooling, gulping • Falling asleep early in the feeding • Feeding time more than 20 to 30 minutes

Common Signs of Pain in Infants

• Increased or decreased heart rate and respirations, apnea • Decreased oxygen saturation • Increased blood pressure • High-pitched, intense, harsh cry • Whimpering, moaning • "Cry face" • Eyes squeezed shut • Grimacing • Bulging or furrowing of the brow • Tense, rigid muscles or flaccid muscle tone • Rigidity or flailing of extremities • Sleep-wake pattern changes

Signs of Nonreadiness for Nipple Feedings

• Respiratory rate >60 breaths per minute • No rooting or sucking • Absence of gag reflex • Excessive gastric residuals

Signs of Readiness for Nipple Feedings

• Rooting • Sucking on gavage tube, finger, or pacifier • Able to tolerate holding • Respiratory rate <60 breaths per minute • Presence of gag reflex

Signs of Overstimulation in Preterm Infants-Behavior Changes

• Stiff, extended arms and legs • Fisting of the hands or splaying (spreading wide apart) of the fingers • Arching • Alert, worried expression • Turning away from eye contact (gaze aversion) • Regurgitation, gagging, hiccupping • Yawning • Fatigue signs

Signs of Fluid Imbalance in the Newborn--Dehydration

• Urine output <2 mL/kg/hr • Urine specific gravity >1.01 • Weight loss greater than expected • Dry skin and mucous membranes • Sunken anterior fontanel • Poor tissue turgor • Blood: elevated sodium, protein, and hematocrit levels

Signs of Fluid Imbalance in the Newborn--Overhydration

• Urine output >5 mL/kg/hr • Urine specific gravity <1.002 • Edema • Weight gain greater than expected • Bulging fontanels • Moist breath sounds • Difficulty breathing • Blood: decreased sodium, protein, and hematocrit levels

Signs that Bonding May Be Delayed

• Using negative terms to describe the infant • Discussing the infant in impersonal or technical terms • Failing to give the infant a name or to use the name • Visiting or calling infrequently or not at all • Decreasing the number and length of visits • Showing interest in other infants equal to that in their own infant • Refusing offers to hold and learn to care for the infant • Showing a decrease in or lack of eye contact • Spending less time talking to or smiling at the infant