Nursing Care of A Family With High-Risk Newborn

Submitted by:
Magyawi, RossJhun A.
Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sadera, Florence Danzel
Sevilla, Shelallae
NURSING CARE OF A FAMILY WITH HIGH-RISK NEWBORN
INTRODUCTION
This chapter adds information about how to care for a newborn who is ill or has a
significant variation in gestational age or weight. This is important information
because learning to recognize these infants at birth and organizing care for them can
be instrumental in helping protect both their present and future health.
During pregnancy, screening women for risk factors that could lead to illness in a
newborn such as younger or older than average maternal age, concurrent disease
condition (e,g.,diabetes or HIV infection),pregnancy complication (e.g., placenta
Previa), or an unhealthy maternal lifestyle (e.g. Drug abuse is essential to identity
infants who need greater than usual care at birth. In addition, an infant who is born
dysmature (before term or post-term, or who is under-or overweight for gestational
age) is also at high risk for complication at birth and in the first few days of life.
Unfortunately, not all instances of high risk can be predicted. Even the newborn from
a “perfect" pregnancy may require specialized care or develop a problem over the
first few days of life necessitating special interventions. With shorter hospital length
of stay for newborns, parents need thorough education about their baby's health
because these problems may require hospitalization or additional follow-up at home.
Being able to predict an infant is at risk allows for advanced preparation so that
specialized, skilled health care personnel can be present at the child's birth to
perform necessary interventions, such as resuscitating a newborn who has difficulty
establishing respirations. Immediate, skilled handling of any problems that occur may
help to save the newborn's life also prevent future problems such as neurologic
disorders.
___________________________________________________________________
Submitted by:
Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
 Summarize assessment and care of the newborn with soft tissue, skeletal,
and neurologic injuries caused by birth trauma.
 Identify maternal conditions that place the newborn at risk for infection.
 Describe the assessment of a newborn exposed to harmful drugs in utero
 Describe risk factors associated with the birth and transition of an infant of a
diabetic mother.
 Plan developmentally appropriate care for the high risk infant.
 Develop a plan to address the unique needs of parents of high risk infants.
 Describe nursing care of the family in the event of a stillbirth or death of a high
risk infant.
 Discuss the identification and care of infants with an inborn error of

metabolism.
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Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
 Identify clinical manifestations of infection in the newborn
- All infants need to be assessed at birth for obvious congenital anomalies and
gestational age (number of weeks the newborn remained in utero).Both
determinations can be done by the nurse who first examines an infant. Be certain
such as first assessment is done under a prewarmed radiant heat warmer to guard
against heat loss.
Continuing assessment of high-risk infants involves the use of technology and

equipment such as cardiac, apnea, oxygen saturation, and blood pressure
monitoring Regardless of how many monitors are used, they do not replace the role
of frequent, close, commonsense observations by a nurse who knows an instant well
from having cared for the baby consistently over time because such a nurse often
senses changes before a monitor or other equipment begins to put a quantitative
measurement on the change. Carefully evaluate comments from fellow nurses such
as an infant "isn't himself" or "breathes irregularly." These comments, although not
evidence based, are the same observations that parents who know their baby well
report at health care Visits.
NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

All newborns have a number of needs in the first few days of life that take priority.
They include:
1. Initiation and maintenance of respirations
2. Establishment of extrauterine circulation
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Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
3. Maintenance of fluid and electrolyte balance

4. Control of body temperature
5. Intake of adequate nourishment
6. Establishment of waste elimination
7. Prevention of infection
8. Establishment of an infant–parent/caregiver relationship
9. Institution of developmental care or care that balances physiologic needs and
stimulation for best development
Indications a newborn is having difficulty making the transition from intrauterine to

extrauterine life may be first apparent by a low Apgar score rating. Not all newborns
will be able to achieve full wellness because of extreme insults to their health during
pregnancy or at birth or because of difficulty preparing for extrauterine life.
Initiating and Maintaining Respirations

Ultimately, the prognosis of a high-risk newborn depends primarily on how the first
moments of life are managed because most deaths occurring during the first 48
hours after birth result from the newborn’s inability to establish or maintain adequate
respirations (National Vital Statistics Service [NVSS], 2011)
An infant who has difficulty breathing may experience residual neurologic morbidities
as a result of cerebral hypoxia. Most infants are born with some degree of respiratory
acidosis, but this is rapidly corrected by the spontaneous onset of respirations. By 2
minutes after birth, the development of severe acidosis is already well under way.
Newborn defense mechanisms then become inadequate to reverse the process.
(Dani, Bresci, Berti, et al., 2013).
An infant who sustains any degree of asphyxia in utero may already be experiencing
acidosis at birth and may have difficulty before the first 2 minutes of life. Struggling to
breathe and circulate blood, the infant is forced to use available serum glucose
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Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
quickly and so may become hypoglycemic, compounding the initial problem even

further.. (Wyckoff et al., 2015).
Common Factors That Predispose Infants to Respiratory Difficulty and So May

Require Resuscitation
Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of

Life Low birth weight
 Intrauterine growth restriction
 Maternal history of diabetes
 Premature rupture of membranes
 Maternal use of barbiturates or narcotics close to birth
 Meconium staining
 Irregularities detected by fetal heart monitor during labor
 Cord prolapse
 Lowered Apgar score (<7) at 1 or 5 minutes
 Postmaturity (postterm)
 Small for gestational age
 Breech birth
 Multiple birth
 Chest, heart, or respiratory tract anomalies
Resuscitation
The American Academy of Pediatrics (AAP) has instituted a Neonatal Resuscitation
Program updated at intervals that lists steps and rationales for newborn
resuscitation. 10% of newborns require some assistance to begin breathing at birth,
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Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
according to the AAP; this can vary from facility to facility and infant to infant.
(Sawyer, Umoren, & Gray, 2017).
Establish an airway, expand the lungs, and initiate and maintain effective positive
pressure ventilation in a newborn. If respiratory depression becomes so severe that
a newborn's heart begins to fail (heart rate is less than 60 beats/min) resuscitation
should then also include chest compressions.. (Wyckoff et al., 2015).
Airway
For a well, term newborn, usually warming, drying the baby by rubbing the back is
enough to initiate respirations. A rubber bulb syringe is a standard piece of
equipment in most birthing rooms and was often used in the past to suction infants'
noses and mouths. But because bradycardia can be associated with bulb suctioning,
it is no longer recommended. (Wyckoff et al., 2015).
If a newborn infant does not initiate spontaneous breathing following gentle

stimulation, place the infant under a radiant heat warmer in a "sniffing" position.
Assess a precordial pulse over the heart and attach a pulse oximeter to monitor
oxygen saturation. It is reasonable to consider the application of a 3-lead cardiac
monitor during resuscitation to obtain an accurate heart rate quickly.. (Wyckoff et al.,
2015).
A newborn whose amniotic fluid was meconium stained at birth but is breathing does
not need suctioning to clear the airway. If the newborn has poor muscle tone and
inadequate breathing, it is important to begin the initial steps of resuscitation under
the warmer. Positive pressure\ventilation should be initiated immediately if the
newborn is not breathing or the heart rate is less than 100 beats/min. (Wyckoff et al.,
2015).
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Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
IN MOST NEWBORNS, MECHANICAL SUCTIONING IS NOT NECESSARY, BUT

SHOULD BE USED ONLY IF THERE IS AN OBSTRUCTION SUCH AS A MUCUS
PLUG THAT IS INTERFERING WITH EFFECTIVE BREATHING.
Suctioning a newborn with mechanical suction controlled by a finger valve. The

suction is applied as the catheter is withdrawn. If the catheter is rotated as it is
withdrawn, the risk of traumatizing the membrane is reduced.
During the first few seconds of life, a newborn may take several weak gasps of air
and then almost immediately stop breathing; the heart rate begins to fall. After 1 or 2
minutes of primary apnea, an infant again tries to initiate respirations with a few
strong gasps. Most infants cannot maintain this effort for more than 4 or 5 minutes
before they enter secondary apnea - a period when breathing becomes increasingly
difficult and may be ineffective. Both types of apnea occur in utero and resuscitation
must be started as soon as possible.. (Wyckoff et al., 2015).
Both types of apnea may occur in utero. Resuscitation must always be started as if
secondary apnea is occurring. Laryngoscope and endotracheal tube insertion should
be present at the birth of infants identified as high-risk for apnea. (Wyckoff et al.,
2015)
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Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
Laryngoscope
INSERTION IS EASY IN THEORY; IN PRACTICE, THE WIDE VARIATION IN THE
SIZE OF INFANTS’ POSTERIOR PHARYNGES AND TRACHEAS AND THE
EMERGENCY CONDITIONS PRESENT UNDER WHICH IT IS ATTEMPTED,
MAKE IT AN OFTEN DIFFICULT PROCEDURE
Intubation. Place the head in a neutral position with a towel under the shoulders. The
blade of the laryngoscope is inserted to reveal the vocal cords. An endotracheal tube
for ventilation is then passed into the trachea, past the laryngoscope.
They are inserted through a tube called an endotracheal tube (think of a thin coffee
straw) into the trachea. Infants under 1,000 g need a 2.5-mm laryngoscope; those
over 3,000g need a 4.0-mm instrument; preterm infants are prone to hemorrhage
because of capillary fragility, so gentle care is crucial.
Lung Expansion
When an infant needs air or oxygen by bag and mask to aid lung expansion, be
certain the mask covers both the mouth and nose. Air (or oxygen if needed) should
be administered at a rate of 40 to 60 ventilations per minute. The pressure needed to
open lung alveoli for the first time can be as high as 40 cm\rH2O. After that,
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Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
pressures of 15 to 20 cm H2O are generally adequate to continue.. (Wyckoff et al.,

2015).
THE PRESSURE FROM ANESTHESIA BAGS IS CONTROLLED SOLELY BY THE

PRESSURE A HEALTHCARE PROVIDER USES WHEN THE HAND SQUEEZES
AGAINST THE BAG. OTHER TYPES OF BAGS SUCH AS THE SELF-INFLATING
(AMBU) BAG CAN BE SET WITH A BLOWOFF VALVE THAT LIMITS THE
PRESSURE IN THE APPARATUS TO BE CERTAIN ONLY GENTLE PRESSURE
IS APPLIED
Types of ventilation bags used in neonatal resuscitation.

(A) The flow-inflating (anaesthesia) bag requires a compressed gas source for
inflation but is able to deliver 100% oxygen. (B) The self-inflating (Ambu) bag
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Pudadera, Joseph
Sevilla, Shelallae
remains inflated at all times and is not dependent on a compressed gas source. It is
limited to delivering oxygen concentration to about 40%.
If a newborn is not breathing adequately, there is little chance of survival if they are
not given adequate ventilation, so it is important to monitor their oxygen saturation
and pressure in addition to auscultating the chest for the sounds of air movement. It
is important not to let oxygen levels in a newborn fluctuate because this can cause
bleeding from immature cranial vessels. (Wyckoff et al., 2015).
The endotracheal tube is probably in the trachea and not the respiratory tract (the
area where air enters and exits the lungs). If air can be heard on only one side or
sounds are not symmetric, the tube is likely blocking the air from entering one of the
main-stem bronchi. Pulling the tube back half a centimetre will usually allow oxygen
to flow to both lungs. If the resuscitation has continued for over 2 minutes, insert an
or gastric tube (through the mouth to the stomach instead of through the nose to the
nose) because babies are obligate nose breathers.
Drug Therapy
Few medications are necessary for newborn resuscitation. Even if an infant's
respiratory episode appears to be related to the administration of a narcotic such as
morphine or Demerol, naloxone (Narcan) should not be routinely administered
because it has little effect and may cause seizures in a newborn. (Leone, Finer, &
Rich, 2012). Instead, resuscitation efforts should focus on effective ventilation and
airway support for the persistently apneic newborn (Wyckoff et al., 2015). If heart
rate continues to be inadequate (less than 60 beats/min), epinephrine 1:10,000 may
be administered intravenously (IV) to stimulate heart action. Preterm infants may
receive surfactant to replace the natural surfactant that has not yet formed in their
lungs.
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Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
Ventilation Maintenance
The first few hours after birth are crucial for a newborn's ability to breathe in and out
of air. A steadily increasing respiratory rate, grunting, and nasal flaring are often the
first\signs of obstruction or respiratory compromise in newborns. Place a newborn
who is having difficulty with maintaining respirations under an infant radiant warmer
to help prevent cooling and acidosis. "Bagging" the infant with a mask and ventilation
bag for a minute before suctioning will usually improve the baby's oxygen level.
Establishing Extrauterine Circulation

if an infant has no audible heartbeat, or if the cardiac rate is below 60 beats/min,
chest compressions should be started. Hold the infant with fingers encircling the
chest and wrapped around the back and depress the sternum at a rate of at least
100 times per minute. (Wyckoff et al., 2015). A newborn's heart rate should be
monitored closely to ensure adequate ventilation. If the heart rate is not above 60
beats/min after 30 seconds of positive-pressure ventilation and chest compressions,
intravenous epinephrine to stimulate heart action may be prescribed. It is possible to
palpate a femoral pulse. (Wyckoff et al., 2015). Following cardiopulmonary
resuscitation, newborns should be transferred to a transitional or high-risk nursery for
continuous cardiorespiratory observation and care to be certain cardiac function is
maintained
Maintaining Fluid and Electrolyte Balance

Infants with hypoglycaemia are treated initially with intravenous 10% dextrose in
water to restore their blood glucose level. Dehydration may also result from
increased insensible water loss caused by rapid respirations. Sodium, additional
glucose, and potassium are added as needed according to electrolyte\laboratory
results. When using a radiant warmer, remember there is a tendency for water loss
from either convection or radiation. A newborn on a warmer may require more fluid
than if he or she were placed in a double-walled incubator. Be certain to monitor the
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Mangirapin, James
Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
rate of fluid administration conscientiously in high-risk infants. Monitor fluid status

both by urine output and urine specific gravity values. An output less than 2 ml/kg/hr
or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. If
hypervolemia is present immediately after birth, the cause is usually fetal blood loss
from placenta previa or twin-to-twin transfusion. The haematocrit may be normal for
some time after acute blood loss, however, because blood cells present are in
proportion to plasma. An isotonic solution (usually saline) may be administered to
increase blood volume. A vasopressor such as dopamine may be given to increase
pressure and improve cell perfusion.
Regulating Temperature
All high-risk infants may have difficulty maintaining temperature because, in addition
to stress from an illness or immaturity, the infant s body is often exposed for long
periods during procedures such as resuscitation. It's important to keep newborns in a
neutral-temperature environment because it places less demand on their
metabolism. If their environment is too hot, they are forced to decrease metabolism
to cool their body. If it's too cold, they must increase their metabolism to warm body
cells. Increased metabolism can be destructive because it calls for increased
oxygen, and without this available, body cells become hypoxic.
In addition to covering the newborn with an infant cap, wiping the body and head dry
with a towel or blanket, and using a radiant warmer or prewarmed incubator suggest
skin-to-skin contact with one of the parents. Additional measures that can be used to
ensure the infant’s temperature stays between 36.5°C and 37.5°C (97.8°F and
99.5°F) axillary are plastic wrap, increasing the room temperature, and warmed
mattresses (Wyckoff et al., 2015). To prevent heat loss, be certain during any
procedure that the infant is not placed on a cool X-ray table or scale.
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Pudadera, Joseph
Sevilla, Shelallae
A neutral thermal environment. (A) A neonate in anintensive care bed with overhead
radiant warmer can be examined periodically with ease. (B) Use of an incubator
allows maintenance of a neutral thermal environment for neonates not requiring
minute-to minute interventions.
Radiant Heat Sources
Radiant heat warmers are open beds that have an attached overhead source of
radiant heat and provide both warmth and visibility for observation. Such units have
small probes, covered by a small shield, often silver metallic, which when placed on
the infant's skin, register the baby's temperature. Abdominal skin temperature, when
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Sevilla, Shelallae
measured, should be 95.9° to 97.7°F (35.5° to 36.5 °C). If an infant's temperature

falls below this level, an alarm on the unit can be set to sound.
Incubators
The temperature of incubators varies with the amount of time portholes remain open
and the temperature of the area in which the incubator is placed. Placing one in
direct sunlight or near a warm radiator can increase the internal temperature
markedly. For these reasons, a newborn's temperature must be assessed at
frequent intervals when in an incubator to be\certain the temperature level is being
maintained. Some incubators have sensors that monitor an infant's body
temperature and change the temperature of the incubator as needed. Dress the
infant as if he or she is going to be in a bassinet, then set the temperature about 2°F
(1.2°C) below normal. After a half hour, assess whether the infant is able to maintain
body. Temperature. If not, the process should be slowed or stopped until the baby is
more mature or better able to self-regulate temperature.
Skin-To-Skin Care
Kangaroo care is the use of skin-to-skin contact with a parent to maintain body heat
for an infant. This method of care not only supplies heat but also encourages parent–
child bonding, according to the American Academy of Family, Child and Human
Services (AAPH). (Moore, Anderson, Bergman, et al., 2012).
Establishing Adequate Nutritional Intake

If an infant's respiratory rate is so rapid that the infant cannot suck effectively,
gavage feedings may be necessary. Others with a long-term nutrition concern may
have gastrostomy tubes placed. Preterm infants should be fed breast milk if at all
possible because of the immune protection this offers. When an infant is too young
to breastfeed, a mother can express her own breast milk or use a breast pump to
initiate and continue her milk supply until the time the infant is mature enough to
breast feed. Her expressed breast milk can then be used in the baby's gavage
feeding. (Martin et al., 2016). Be certain when bottled breast milk is that it is well
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Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
marked with the infant's name, date and time it was pumped, and medical record
number or breast milk errors can occur the same as those caused by medication
errors (Centers for Disease Control and Prevention [CDC], 2016). It should be stored
in polycarbonate- (bisphenol A) free plastic bags or bottles, which can leech into
stored milk and possibly lead to endocrine disruptions (Trasande, 2014).
Infants Who Are Ill At Birth Often Need Supplemental Feedings By Nasogastric
Or Gastrostomy Tube.
Preterm infants who use a pacifier at feeding times are more likely to show signs of
hunger - such as rooting, crying and sucking motions - than those who are gavage or
gastrostomy fed. In immature infants, this may be because they need oral stimulation
from non-nutritive sucking so seem to enjoy using the pacifier more. (Alm,
Wennergren, Möllborg, et al., 2016). Exceptions include infants who must not
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Nonan, Maria wena
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Sevilla, Shelallae
swallow air, such as those with a tracheoesophageal fistula awaiting surgery; or

those mature enough to breastfeed. The techniques of gavage feeding and
gastrostomy feeding are discussed.
Establishing Waste Elimination
Most immature infants void within 24 hours of birth, but they may void later as their
blood pressure may not be high enough to supply their kidneys. Immature infants
also may pass stool later because meconium has not yet reached the end of the
intestine's intestine-rat birth stage. Carefully document any voiding’s that occur
during resuscitation because this is proof that hypotension is improving and the
kidneys are being perfused.
Preventing Infections
Infections in high-risk newborns may occur from prenatal, perinatal, or postnatal
causes. The risk of preterm premature rupture of the membranes is what places the
infant in a ‘high-risk category’ for developing brain and nervous system damage.
(Committee on Practice Bulletins-Obstetrics, 2016). Contracting an infection has the
potential to drastically complicate a high-risk newborn’s ability to adjust to
extrauterine life, another reason breastfeeding is good for such infants because,
beginning with colostrum, it supplies important immune protection (Verardo, Gómez-
Caravaca, Arráez-Román, et al., 2017). Perinatal infections are those contracted
from the vaginal canal during birth, such as herpes simplex 2 and hepatitis B. Early-
onset sepsis is most commonly caused by group B streptococcus, Escherichia coli,
Klebsiella, and Listeria monocytogenes. Hospital-acquired infections are probably
most commonly spread to newborns from healthcare personnel. All persons coming
in contact with or caring for infants should observe good hand washing techniques.
Establishing Parent–Infant Bonding

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Nonan, Maria wena
Operana, Lexus
Pudadera, Joseph
Sevilla, Shelallae
Parents of high-risk babies should be offered a tour of a neonatal intensive care unit
(NICU) during pregnancy so they will be more comfortable in the high-tech
environment. They should also be able to visit the special nursing run it where the
infant is admitted as soon as possible and as often as they choose. If an infant does
not survive initial illness, these interactions can also help make the death more real
and can help parents work through their feelings. If an infant dies despite newborn
resuscitation attempts, parents need to see the baby when no longer attached to
equipment. Urge parents to spend as much time with their infant in the intensive care
unit as possible. Viewing the baby can help reassure them that the baby was a
perfect newborn in every other way except lung function or whatever was the infant's
specific fatal disorder.
Anticipating Developmental Needs
High-risk newborns need special care to ensure the amount of pain they experience
is limited. Most high-risk infants experience "catch-up" growth once they stabilize
from trauma of birth. Some parents may need support before and after their infant is
discharged home. Discussing usual growth and development of infants can help
prepare them and look forward to the next developmental step.
Follow-Up of the High-Risk Infant at Home

Parents should assess their level of knowledge about their child's condition and
development each time they visit a special intensive care nursery. Transporting a
preterm infant in a car will require special measures, including a commercial head
support because a very small infant does not fit securely into a standard infant car
seat. Some preterm infants experience episodes of oxygen desaturation, apnea or
bradycardia when seated in standard car safety seats. (Davis, 2015). To detect if this
will occur, the AAP recommends all preterm infants be assessed for
cardiorespiratory stability in their car seat prior to discharge from the healthcare
facility—the “car seat challenge” (AAP,2012).
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High-Risk Infants and Child Maltreatment

When a child is born ill or preterm, the expected reaction of parents is to protect
them even more than they would if they were healthy. This may be related to the
feeling they are "different" or because they were separated from the parents for a
long time following birth. (Nandyal, Owora, Risch, et al., 2013).
THE NEWBORN AT RISK BECAUSE OF ALTERED GESTATIONAL AGE OR

BIRTH WEIGHT
Infants need to be evaluated as soon as possible after birth to determine their

weight, height, head circumference, and gestational age to determine their
immediate healthcare needs and to help anticipate possible future problems.
Term infants are those born after the beginning of week 38 and before week 42 of
pregnancy (calculated from the first day of the last menstrual period). Infants born
before term (before the beginning of the 38th week of pregnancy) are classified as
preterm infants regardless of their birth weight. Infants born after the end of week
41 of pregnancy are classified as post term infants or post mature.
Infants who fall between the 10th and 90th percentiles of weight for their gestational
age, whether they are preterm, term, or post term, are considered appropriate for
gestational age (AGA). Infants who fall below the 10th percentile of weight for their
age are considered small for gestational age (SGA). Those who fall above the 90th
percentile in weight are considered large for gestational age (LGA). Other terms
used include:
• Low–birth-weight (LBW) infant: one weighing less than 2,500 g at birth
• Very-low-birth-weight (VLBW) infant: one weighing less than 1500 g at birth
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• Extremely-low-birth-weight (ELBW) infant: one weighing less than 1,000 g at

birth
The Preterm Infant
A preterm infant is traditionally defined as a live-born infant born before the end of
week 37 of gestation. Neonatal assessments such as inspection for sole creases,
skull firmness, ear cartilage, and neurologic development plus the mother’s report of
the date of her last menstrual period along with a sonographic estimation of age all
can be helpful to determine gestational age.
Most preterm infants need intensive care from the moment of birth to give them their
best chance of survival without neurologic after effects because they are more prone
than others to hypoglycemia and intracranial hemorrhage. Lack of lung surfactant,
because this does not form until about the 34th week of pregnancy, makes them
extremely vulnerable to respiratory distress syndrome.
Characteristics between Small-For-Gestational-Age and Preterm Infants

Characteristic Small-for-Gestational- Preterm Infant
Age
Infant
Gestational age 24–44 wk <37 wk
Birth weight <10th percentile Normal for age
Congenital Strong possibility Possibility

malformations
Pulmonary Meconium aspiration, Respiratory distress
problems most pulmonary hemorrhage, syndrome
apt to occur pneumothorax

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Hyperbilirubinemia Possibility Very strong possibility
Hypoglycemia Very strong possibility Possibility
Intracranial Strong possibility Possibility

hemorrhage
Apnea episodes Possibility Very strong possibility
Feeding problems Most likely because of Small stomach capacity;

accompanying problem immature sucking reflex
such as hypoglycemia
Weight gain in Rapid Slow

nursery
Future restricted Possibly always be Not likely to be
growth <10th restricted in growth
percentile because of because “catch-up”
poor growth occurs
organ development
Etiology
At least 50% of neonatal deaths are preterm. Infant mortality could be reduced
dramatically if the causes of preterm birth could be discovered and corrected and all
pregnancies could be brought to term. However, even with the examples of possible
causes listed in the following, the exact cause of premature labor and early birth is
rarely exactly known.
Common Factors Associated With Preterm Birth

• Low socioeconomic level
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• Poor nutritional status

• Lack of prenatal care
• Multiple pregnancy
• Previous early birth
• Race (non-Whites have a higher incidence of prematurity than Whites)
• Cigarette smoking
• Age of the mother (highest incidence is in mothers younger than age 20
years)
• Order of birth (early birth is highest in first pregnancies and in those beyond
the
 fourth pregnancy)
• Closely spaced pregnancies
• Abnormalities of the mother’s reproductive system, such as intrauterine
septum
• Infections (especially urinary tract infections)
• Pregnancy complications, such as premature rupture of membranes or
premature
 separation of the placenta
• Early induction of labor
• Elective caesarean birth
Assessment
When interviewing parents of a preterm infant, be careful not to convey disapproval
of reported pregnancy behaviors such as cigarette smoking that may have
contributed to preterm birth. An accurate but comforting answer to a direct inquiry
about why preterm birth occurs is, “No one really knows what causes prematurity.”
On gross inspection, a preterm infant’s head appears disproportionately large (≥3 cm

greater than chest size). The skin is generally unusually ruddy because there is so
little subcutaneous fat beneath it, making veins easily noticeable; a high degree of
acrocyanosis may be present. Newborns delivered at greater than 28 weeks of
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gestation are typically covered with vernix caseosa. In very preterm newborns,
however (less than 28 weeks of gestation), the vernix will be lacking. Lanugo is
usually scant the same way in very low gestation infants but will be extensive,
covering the back, forearms, forehead, and sides of the face in late preterm babies.
Both anterior and posterior fontanelles will be small. There are few or no creases on
the soles of the feet.
An immature newborn at birth. (Photodisc/PunchStock.)

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Examples of physical examination findings and reflex tests used to judge gestational
age. (A) A resting posture. (B) Wrist flexion. (C) Recoil of extremities (legs). (D) The
scarf sign. (E) Heel to ear. (F) Plantar creases. (G) Breast tissue. (H) Ears. (I) Male
genitalia. (J) Female genitalia.
The eyes of most preterm infants appear small in relation to term infants. Although
difficult to elicit, a pupillary reaction is present. A preterm infant has varying degrees
of myopia (nearsightedness) because of a lack of eye globe depth.
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The ears appear large in relation to the head. The cartilage of the ear is
immature and allows the pinna to fall forward. The level of the ears should be
carefully inspected to rule out chromosomal abnormalities
Neurologic function in the preterm infant is often difficult to evaluate because
the neurologic system is still immature. Observing the infant make spontaneous or
provoked muscle movements can be as important as formal reflex testing. During an
examination, a preterm infant is much less active than a mature infant and rarely
cries. If the infant does cry, the cry is weak and high pitched.
Potential Complications
Because of immaturity, preterm infants are prone to several specific conditions
Anemia of Prematurity
Many preterm infants develop a normochromic, normocytic anemia (normal cells,
just few in number), which can make infants appear pale, lethargic, and anorectic.
Anemia occurs from a combination of immaturity of the hematopoietic system (the
effective production of red cells with an elevated reticulocyte count may not begin
until 32 weeks of pregnancy) combined with the destruction of red blood cells
because of low levels of vitamin E, a substance that normally protects red blood cells
against oxidation. Excessive blood drawing for electrolytes, complete blood counts,
or blood gas analysis after birth can potentiate the problem. Delaying cord clamping
at birth to allow a little more blood from the placenta to enter the infant may also help
reduce the development of anemia.
Acute Bilirubin Encephalopathy

Acute bilirubin encephalopathy (ABE) is the destruction of brain cells by invasion
of indirect or unconjugated bilirubin. This invasion results from the high concentration
of indirect bilirubin that forms in the bloodstream from an excessive breakdown of
red blood cells at birth. Preterm infants are more prone to this condition than term
infants because, with the acidosis that occurs from poor respiratory exchange, brain
cells appear to be more susceptible to the effect of indirect bilirubin than usual.
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Preterm infants also have less serum albumin available to bind indirect bilirubin and
inactivate its effect.
Persistent Patent Ductus Arteriosus

Because preterm infants may lack surfactant, their lungs are noncompliant, so it is
more difficult for them to move blood from the pulmonary artery into the lungs. This
condition leads to pulmonary artery hypertension, which then interferes with closure
of the ductus arteriosus.
Periventricular/Intraventricular Hemorrhage
Preterm infants are prone to periventricular hemorrhage (bleeding into the tissue
surrounding the ventricles) or intraventricular hemorrhage (bleeding into the
ventricles) because of fragile capillaries and immature cerebral vascular
development. When there is a rapid change in cerebral blood pressure, such as
could occur with hypoxia, intravenous infusion, ventilation, or pneumothorax (lung
collapse), capillary rupture could occur; brain anoxia then occurs distal to the
rupture.
Intraventricular hemorrhage occurs most often in VLBW infants and is classified as:
• Grade 1, bleeding in the periventricular germinal matrix regions or germinal
• matrix, occurring in one ventricle
• Grade 2, bleeding within the lateral ventricle without dilation of the ventricle
• Grade 3, bleeding causing enlargement of the ventricles
• Grade 4, bleeding in the ventricles and intraparenchymal hemorrhage
A long-term effect of hemorrhage may be the development of hydrocephalus if there

was bleeding into the narrow aqueduct of Sylvius. Infants with grade 1 or 2 bleeds
have a good long-term prognosis; the prognosis of those with more intense bleeds is
guarded until further complications are ruled out.
Other Potential Complications

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Preterm infants are also particularly susceptible to several illnesses in the early
postnatal period, which can also occur in term infants, including respiratory distress
syndrome, apnea, and retinopathy of prematurity, as well as necrotizing enter colitis.
Nursing Diagnoses and Related Interventions
Nursing Diagnosis Risk: Impaired gas exchange related to immature pulmonary

functioning.
Outcome Evaluation: Newborn initiates breathing at birth after resuscitation;

maintains normal newborn respirations of 30 to 60 breaths/min free of assisted
ventilation; exhibits oxygen saturation levels of at least 95% as evidenced by pulse
oximetry.
Preterm infants have great difficulty initiating respirations at birth because pulmonary
capillaries are still so immature, and lung surfactant, which does not form in
adequate amounts until about the 34th to 35th week of pregnancy, may not be
present. Inadequate lung surfactant leads to alveolar collapse with each expiration.
Even term infants experience temporary respiratory acidosis until they take a
first breath. Once respirations are established, however, this condition quickly clears.
Many preterm babies, particularly those under 32 weeks of age, continue to
have an irregular respiratory pattern. There is no bradycardia with this irregular
pattern (sometimes termed periodic respirations). If true apnea, which needs
immediate attention, is occurring, the pause in respirations is more than 20 seconds
and usually results in bradycardia
The soft rib cartilage of a preterm infant is yet another source of respiratory
problems because it causes ribs to collapse on expiration.
Nursing Diagnosis: Risk for deficient fluid volume related to insensible water
loss at birth and small stomach capacity
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Outcome Evaluation: Plasma glucose is between 40 and 60 mg per 100 ml;

specific gravity of urine is maintained at 1.003 to 1.020; urine output is maintained at
a minimum of 1 ml/kg/hr; electrolyte levels are within normal limits.
A preterm newborn experiences a high insensible water loss because of a

large body surface relative to total body weight. Preterm infants also cannot
concentrate urine well because of immature kidney function. Because of this, a high
proportion of body fluid is excreted. All these factors may make a preterm baby need
a higher percentage of fluid daily than a term infant
The amount of urine output for the first few days of life in preterm babies is
high in comparison with that of the term baby because of poor urine concentration:
40 to 100 ml/kg per 24 hours, compared with 10 to 20 ml/kg per 24 hours,
respectively. The specific gravity is low, rarely more than 1.012 (normal term babies
may concentrate urine up to 1.030).
Blood glucose determinations should range between 40 and 60 mg/dl. Check
for blood in stools to evaluate possible bleeding from the intestinal tract because this
can help determine a cause of hypovolemia if this occurs.
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements,
related to additional nutrients needed for maintenance of rapid growth, possible
sucking difficulty, and small stomach
Outcome Evaluation: Infant’s weight follows percentile growth curve, skin turgor is
good, specific gravity of urine is maintained between 1.003 and 1.020; the infant has
no more than 15% weight loss in the first 3 days of life and continues to gain weight
after this point.
Nutrition problems can arise with a preterm infant because the infant’s body is
attempting to continue to maintain the rapid rate of intrauterine growth appropriate
for the gestational age.
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If these nutrients are not supplied, an infant can develop hypocalcaemia

(decreased serum calcium) or azotemia (low protein level in the blood). Delayed
feeding and a resultant decrease in intestinal motility may also add to
hyperbilirubinemia, a problem infants already are at high risk of developing when
fetal red blood cells begin to be destroyed.
Digestion and absorption of nutrients in a preterm infant’s stomach and
intestine may be immature, making the digestion of milk difficult. Nutrition problems
are further compounded by a preterm infant’s immature reflexes, which make
swallowing and sucking difficult. An immature cardiac sphincter (between the
stomach and esophagus) allows regurgitation to occur readily. The lack of a cough
reflex may lead an infant to aspirate regurgitated formula.
Feeding Schedule. With the early administration of intravenous fluid to prevent

hypoglycemia and supply fluid, feedings may be safely delayed until an infant has
stabilized his or her respiratory effort from birth. Very preterm infants may be fed by
total parenteral nutrition until they are stable enough for enteral feedings. Breast,
gavage, or bottle feedings are then begun as soon as the infant is able to tolerate
them to prevent the deterioration of the intestinal villi.
Gavage Feeding. Although a sucking reflex is present earlier, the ability to

coordinate sucking and swallowing is inconsistent until approximately 34 weeks of
gestation. A gag reflex is not intact until 32 weeks of gestation. For this reason, for
infants who are ill or experiencing respiratory distress may be started on gavage
feedings; bottle feeding or breastfeeding will then be gradually introduced as the
infant matures and begins to demonstrate feeding behaviors such as being awake,
moving, or fussing as if hungry.
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Feeding a preterm infant. Notice the small bottle used. (Fuse/PunchStock.)
Observe preterm infants closely after oral or gavage feeding to be certain their
filled stomach is not causing respiratory distress. Offering a pacifier during gavage
feeding can help strengthen the sucking reflex, better prepare an infant for bottle
feeding or breastfeeding, and provide oral satisfaction.
Gavage feedings may be given intermittently every few hours or continuously
via tubes passed into the stomach or intestine through the mouth or nose. This can
be helpful for infants on ventilators or those who cannot tolerate intermittent feedings
because of the volume. If feedings are given intermittently, stomach contents may be
aspirated, measured, and replaced before each feeding. Feedings should not be
increased and possibly even cut back to ensure better digestion and to decrease the
possibility of regurgitation and aspiration.
Breast Milk. There is increasing evidence that although preterm infants grow well on
commercial formulas, the best milk for them, the same as with term infants, is breast
milk. The immunologic properties of breast milk may play a major role in preventing
neonatal necrotizing enter colitis as well as an increase in immune defenses.
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Mothers can express breast milk manually or with a breast pump for their
infant’s gavage feedings. It is better for infants to receive their own mother’s breast
milk rather than banked milk if possible. This high level of sodium seems to be
necessary for fluid retention in the preterm infant.
Formula. The caloric concentration of formulas used for preterm infants is usually 22
calories per ounce compared to 20 calories per ounce for a term baby.
Supplementing additional minerals such as iron, calcium, and phosphorus and
electrolytes such as sodium, potassium, and chloride may be necessary, depending
on the newborn’s blood studies.
Nursing Diagnosis: Ineffective thermoregulation related to immaturity
Outcome Evaluation: Infant’s temperature is maintained at 97.6°F (36.5°C) axillary.
Preterm newborns have a great deal of difficulty maintaining body temperature

because they have a relatively large surface area per kilogram of body weight.
A preterm infant has little subcutaneous fat for insulation and poor muscular
development and so cannot move as actively as an older infant to produce body
heat. A preterm infant also has a limited amount of brown fat, the special tissue
present in newborns that helps maintain body temperature. Preterm infants also
cannot shiver, a useful mechanism to increase body temperature, nor can they
sweat and thereby reduce body temperature because of their immature central
nervous system and hypothalamic control.
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If an infant is going to be transported to a department within the hospital, such

as the X-ray department, or to a regional center for specialized care, keeping the
newborn warm during transport is crucial.
Nursing Diagnosis: Risk for infection related to immature immune defenses in the
preterm infant
Outcome Evaluation: Temperature is maintained at 97.6°F (36.5°C) axillary; further

signs and symptoms of infection such as poor growth or a reduced temperature are
absent.
The skin of a preterm infant is easily traumatized and therefore offers less resistance
to infection than the skin and mucous membrane of a mature infant. In addition,
preterm infants have a lowered resistance to infection because they have difficulty
producing phagocytes to localize infection as well as a deficiency of immune globulin
M (IgM) antibodies because of insufficient production.
Nursing Diagnosis: Risk for impaired parenting related to interference with parent–
infant attachment resulting from hospitalization of infant at birth
Outcome Evaluation: Parents visit frequently and hold the infant; parents speak of
their child in positive terms.
In a preterm infant, the first and second periods of reactivity normally observed in
newborns at 1 hour and 4 hours of life may be delayed. In some infants, no period of
increased activity or tachycardia may appear until 12 to 18 hours of age. If the
purpose of a period of reactivity is to stimulate respiratory function, this places a
preterm infant at an even greater threat of respiratory failure because respiratory
efforts may not be stimulated. A second consequence of a delayed period of
reactivity is the loss of an opportunity for interaction between parents and the
newborn in the early postpartum period.
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Although it is extremely important to conserve a preterm infant’s strength by

reducing sensory stimulation as much as possible and handling an infant gently,
preterm infants appear to need as much attention and affection as term newborns.
Nursing Care Planning to Empower a Family
Here are some guidelines that should be helpful:
- Learn the name of your child’s primary healthcare provider and primary
nurse or care manager. Make a point of talking to them when you visit
so the information you receive is consistent and so these important
people can get to know you.
- Discuss with your child’s primary nurse the time you will usually visit so
she or he can schedule your baby’s procedures and rest times other
than when you visit so there is time for you to hold your child and
interact with him uninterrupted
- Ask for explanations of any equipment or medications being used with
your child so you understand the plan of care.
- Any day you are unable to visit, call the nursery and ask to talk to your
child’s primary care nurse.
- Ask if you can supply expressed breast milk for your infant as soon as
feedings are started so you can feel you’re having a greater part in
your baby’s care.
- You might supply a tape recording of your voice so your baby can learn
to recognize it, as well as supply a small toy for your baby’s bed.
- Use your baby’s name when you talk about him (not “the baby”) to help
you gain a firm feeling that this is your baby, not the nursery’s.
- If your child is hospitalized a distance from home, ask if transfer to a
local hospital in a less technical environment will be possible as soon
as he’s not so ill.
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Before effective bonding can be established, parents may need time to come to
terms with their feelings of disappointment that the infant is so small or guilt that they
were not able to prevent the preterm birth. Helping them air these feelings and
develop a more positive attitude toward their preterm infant is an important nursing
responsibility.
Because parents may not be psychologically ready for birth when a preterm
infant is born, it may be more difficult for them to believe they have a child and to
begin interacting than if the infant had been born at term. Encourage the mother to
come to the nursery and hold the infant before and after gavage feedings and to
breastfeed or bottle feed as soon as the baby is ready for this.
If the baby is going to be transferred to a regional center, make sure the
parents have an opportunity to see the infant before the transfer. A photograph of the
infant for them to keep is helpful in making the birth more real.
On days they cannot visit, parents can still stay in touch by telephone, video,
or nursery e-mail. By these means, by the time the baby is ready for discharge, the
parents should be able to feel they are taking home “their” baby, one whom they
know and have already begun to love.
Parents visiting a high-risk nursery often need a great deal of support from
nursing personnel. In such a high-tech setting, a parent may want very much to
touch his or her infant but is so afraid touching might set off an alarm that he or she
stands with arms folded
Nursing Care Planning Tip for Effective Communication

Visiting a NICU can be intimidating for parents, not only because of the high-tech
equipment that surrounds their baby but also because their baby often appears
much smaller or sicker than they imagined.
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Encourage families to visit with immature infants to establish bonding. (Phanie/Alamy

Stock Photo)
Because preterm infants can be hospitalized for long periods, parents can feel
baffled by receiving information from a parade of different healthcare providers or a
different person every time they visit. Consistent caregiver helps to reduce the
number of people who contact the parents and who communicate the parents’ needs
to the rest of the staff.
Try to make a baby’s siblings as welcome in a high-risk nursery as the baby’s
parents in order to build family unity. Check to be certain siblings do not have an
upper respiratory infection or fever. Also, their immunizations should be up to date
and they should not have been recently exposed to a communicable disease, such
as chickenpox, before they visit
Nursing Diagnosis: Deficient diversional activity (lack of stimulation) related to

preterm infant’s rest needs
Outcome Evaluation: Infant demonstrates interaction with caregivers by attuning to

faces or voices. Preterm infants need rest to conserve energy for growth and
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respiratory function, to combat hypoglycemia and infection, to stabilize temperature,

and to develop inner balance and attentiveness. Preterm infants may have more
difficulty blocking out stimuli than term infants do because their nervous systems are
so immature. They may demonstrate they are overstimulated by such behaviors as
gagging, crying, splaying fingers and toes, or going limp when exposed to bright
lights, noise, pain, or overly strenuous handling. Until ready to take in stimuli, the
infant may need to be shielded from noise and light and pain may need to be limited
as much as possible.
Just as a preterm infant needs rest, he or she also needs planned periods of
pleasing sensory stimulation. Like all newborns, preterm infants respond best to
stimulation that appeals to their senses of sight, sound, and touch.
The acrylic dome of an incubator can distort an infant’s view. Also, most
people view an infant in an incubator with themselves standing up and the infant
lying horizontally. This means that an infant’s face is rarely in the same line of vision
as the adult’s (an en face position). As infants mature, they should have mobiles
(perhaps black and white) or bright objects placed in view. As an infant’s position is
changed from the left side to the right side, move the object to be in line with the
child’s vision
Infants in closed incubators may be able to hear nothing but the sound of the
incubator motor. They may see people looking or nodding at them and may see their
mouths moving, but they cannot benefit from the sound of their voices because this
is obscured by the continuous hum of the motor. Even an infant who cannot be
removed from an incubator should not suffer from lack of touch. Gently stroking an
infant’s back or smoothing the back of the head should not be tiring. Pulse oximetry
can be used to help you recognize when an infant is comforted by handling (e.g.,
oxygen saturation remains steady or increases) and when the infant is growing tired
(e.g., oxygen saturation falls). Be certain during every nursing shift that close
interaction is provided, particularly if clinical interventions with an infant include
uncomfortable procedures such as suctioning or blood drawing. As soon as infants
can be out of incubators or removed from warmers, they need special time just to be
rocked and held.
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Nursing Diagnosis: Risk for disorganized infant behavior related to prematurity and
environmental overstimulation
Outcome Evaluation: Newborn’s vital signs remain within normal limits; infant
demonstrates increasing ability to adapt to stimuli; demonstrates decreasing levels of
irritability, crying, respiratory pauses, tachypnea, and color changes.
The amount of rest and stimulation required by preterm infants for healthy
development is best individualized. Developmental care (care designed to meet the
specific needs of each infant) can lead to increased weight gain and decreased
crying and apnea spells in preterm infants.
Developmental Care
Developmental care is medical attention specially tailored to a preterm infant's
needs. Behavioral cues to accommodate a preterm or newborn baby's unique needs.
Common measures consist of a parent welcoming procedure. Make parents feel
welcome in a neonatal intensive care environment by both words and actions.
Provide room around incubators or warmers for rocking chairs so parents can hold
their baby comfortably. Encourage parent participation in feeding or supplying non
nutritive sucking experiences. Demonstrate the infant's capabilities and how,
although immature, these are correct for the infant's age or weight. Keep parents
informed of their baby's progress and the rationale for therapies. Ask parents for
input into their baby's rhythm of care that will best suit them and the infant after they
return home.
Infant Developmental Procedures

 Provide a consistent routine to help the infant develop sleep/wake cycles.
 Time infant care and feeding based on the sleep/wake cycle of the infant.
 Cluster aspects of care so the infant enjoys the longest possible sleep
intervals to conserve energy.
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 Provide a "nest" with blankets to offer a sense of boundaries or security.

 Position infants so they can self-soothe-curled on side, or hands near face,
knee tucked near body, or whatever way each baby seems to prefer.
 Provide quiet or rest times by covering an incubator and limiting sound.
 Provide tactile stimulation by back stroking or massage.
 Provide audio and visual stimulation by the use of mobiles and music or a
parent's voice.
 Halt procedures as soon as the infant evidences stress.
Nursing Diagnosis: Parental health-seeking behaviors related to preterm infant's

needs for health maintenance
Outcome Evaluation: Parents describe schedule for basic immunizations and

health assessments and state who will provide ongoing health care.
Discharge from a NICU is a major transition for parents as well as their infant. Before
discharge, the parents of a preterm infant need to learn and practice any special
methods of care necessary for their infant and interventions to help maximize their
child's development. Some parents tend to overprotect preterm infants, such as not
allowing visitors or not taking an infant outside. Let parents know their concern is
normal but overprotection is not necessary. Ongoing health maintenance of a
preterm infant follows the usual pattern of well-child care. Basic immunizations are
given according to the chronologic age of an infant. In many communities, NICUs
maintain their own well-child settings for infants who were hospitalized there.
However, preterm infants can be followed by any healthcare provider for well-child
care. When plotting the height and weight of preterm infants at well-child visits,
remember to account for early birth on the growth chart by double charting-that is,
plotting the child's weight and height according to the chronologic age (a pattern that,
in the early months, probably places the child below the 10th percentile). Then, in
another color, plot the height and weight according to an infant's adjusted age, or
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plot the weight of a baby born 2 months early 2 months earlier on the graph. A
preterm baby typically gains "catch-up" weight in the first 6 months of life, so by 1
year of age, a baby plots over the 10th percentile on a growth chart without
accounting for a setback age.
THE SMALL-FOR-GESTATIONAL-AGE INFANT
An infant is SGA (also called microsomal) if the birth weight is below the 10th
percentile on an intrauterine growth curve for that age. Such infants may be born:
Preterm: before week 38 of gestation
Term: between weeks 38 and 42
Post term: past 42 weeks
Etiology
A woman's nutrition during pregnancy plays a major role in fetal growth, so a lack of
adequate nutrition may be a major contributor to IUGR (Ota, Tobe-Gai, Mori, et Al.
2012). Adolescents are prone to having a high incidence of SGA infants because if
they eat only enough to meet their own nutritional and growth needs, the needs of a
growing fetus can be compromised. In still other instances, the placental supply of
nutrients is adequate but an infant cannot use them because of a chromosomal
abnormality or an intrauterine infection such as rubella or toxoplasmosis. Even in
light of these nutritional influences, the most common cause of IUGR is a placental
issue: either the placenta did not obtain sufficient nutrients from the uterine arteries
or unit was inefficient at transporting nutrients to the fetus.
Assessment
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The SGA infant may be detected in utero when fundal height during pregnancy
becomes progressively less than expected. However, if a woman is unsure of the
date of her last menstrual period, this discrepancy can be hard to substantiate; a
sonogram can then demonstrate the decreased size. A biophysical profile including a
non-stress test, placental grading, amniotic fluid amount, and an ultrasound
examination documents additional information on placental function and fetal growth.
Appearance
Generally, an infant who suffers nutritional deprivation early in pregnancy, when
fetal growth consists primarily of an increase in the number of body cells, is below
average in weight, length, and head circumference. An infant who suffers deprivation
late in pregnancy, when growth consists primarily of an increase in cell size, may
have only a reduction in weight. Regardless of when deprivation occurs, the infant
tends to have an overall wasted appearance:
 The infant may have poor skin turgor and generally appears to have a large
head because the rest of the body is so small.
 Skull sutures may be widely separated. Hair may be dull and lusterless
 The infant may have a small liver, which can cause difficulty regulating
glucose, protein, and bilirubin levels after birth.
 The abdomen may be sunken. The umbilical cord often appears dry and may
be stained yellow.
Laboratory Findings
Blood studies at birth usually show a high hematocrit level (less than normal
amounts of plasma in proportion to red blood cells are present because of a lack of
fluid) and an increase in the total number of red blood cells (polycythemia). The
increase in red blood cells occurs because anoxia during intrauterine life stimulated
excess development of them. An immediate effect of polycythemia is to cause
increased blood viscosity, a condition that puts extra work on the infant's heart
because it is more difficult to effectively circulate thick blood. As a consequence,
acrocyanosis (blueness of the hands and feet) may be prolonged and persistently
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more marked than usual. If the Polycythemia is extreme, vessels may actually
become blocked and thrombus formation can result. If the hematocrit level is more
than 65% to 70%, an exchange transfusion to dilute the blood may be necessary.
Nursing Diagnosis: Ineffective breathing pattern related to underdeveloped body

systems at birth.
Outcome Evaluation: Newborn maintains respirations at a rate of 30 to 60

Breaths/min after resuscitation at birth.
Birth asphyxia is a common problem for SGA infants, both because they have
underdeveloped chest muscles and because they are at risk for developing
meconium aspiration syndrome (MAS) as a result of meconium release, which
occurs when fetal anoxia develops during labor to cause reflex relaxation of the anal
sphincter. When gasping for breath in utero, the fetus draws meconium discharged
from the intestine into the amniotic fluid down into the trachea and bronchi. Acting as
a foreign substance, this blocks airflow into the alveoli and causes the SGA infant to
need resuscitation at birth. Closely observe both respiratory rate and character in the
first few hours of life as underdeveloped chest muscles not only make taking the first
breath difficult but can make SGA infants unable to sustain an adequate newborn
respiratory rate.
Nursing Diagnosis: Risk for ineffective thermoregulation related to lack of

subcutaneous fat.
Outcome Evaluation: Infant's temperature is maintained at 36.5°C (97.8°F) axillary.
The Large-For-Gestational-Age Infant

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Pudadera, Joseph
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An infant is LGA (also termed macrosomia) if the birth weight is above the 90th
percentile on an intrauterine growth chart for that gestational age. Such a baby
appears deceptively healthy at birth because of the weight, but a gestational age
examination often reveals immature development. It is important that LGA infants be
identified immediately so they can be given care appropriate to their gestational age
rather than being treated as term newborns (Sjaarda, Albert, Mumford, et al., 2014).
Etiology
Infants who are LGA have been subjected to an overproduction of nutrients and
growth hormone in utero. This happens most often to infants of women who are
obese or why have diabetes mellitus (Sjaarda et al., 2014).
Assessment
A fetus is suspected of being LGA when a woman's uterus appears to be
unusually
Large for the date of pregnancy. Abdominal size can be deceptive, however.
Because a fetus lies in a flexed fetal position, he or she does not occupy significantly
more space at10 b than at 7 lb. If a fetus does seem to be growing at an abnormally
rapid rate, a sonogram can confirm the suspicion. A non-stress test to assess the
placenta's ability to sustain a large fetus during labor may be prescribed. Lung
maturity may be assessed by amniocentesis If an infant's large size was not
detected during pregnancy, it may be first recognized during labor when the baby
appears too large to descend through the pelvic rim. If this happens, a cesarean birth
may be necessary because shoulder dystocia (the wide fetal shoulders cannot pass;
or needs significant manipulation to pass through the outlet of the pelvis) would halt
vaginal birth at that point.
Appearance
At birth, LGA infants may show immature reflexes and low scores on gestational age
examinations in relation to their size. They may have extensive bruising or a birth
injury such as a broken clavicle or Erb-Duchenne paralysis from trauma to the
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cervical nerves if they were stressed in order for the wide shoulders to be born
vaginally. Because the head is large, it may have been exposed to more than the
usual amount of pressure during birth, causing a prominent caput succedaneum,
cephalohematoma, or molding. Often immature, they require cautious.
Important Assessment Criteria for a Large-For-Gestational-Age Infant
Assessment Rationale
Assess skin color for ecchymosis, Bruising occurs with vaginal birth
polycythemia jaundice, and erythema Because of the large size; polycythemia
jaundice, and erythema causes ruddiness
of skin. Ecchymosis is important to
document because jaundice may occur
from breakdown chymotic collections of
blood.
Assess motion of upper extremities is

occur because of problem at birth of
Clavicle or cervical nerve injuries may
Spontaneous and also occurs in
Assess motion of upper extremities is
response wider than usual shoulders.
occur because of problem at birth of
to a Moro reflex to detect if clavicle
Spontaneous and also occurs in
Fracture (crepitus or swelling may then
response wider than usual shoulders.
be palpated at the fracture site) or Erb's
palsy caused by edema of the cervical
nerve plexus are present.
Assess asymmetry of the anterior chest

or unilateral lack of movement to detect The cervical nerve may be stretched by
the phrenic nerve. birth of wide shoulders.
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Assess asymmetry of the anterior chest The cervical nerve may be stretched by
or unilateral lack of movement to detect birth of wide shoulders.
diaphragmatic paralysis from edema of
the phrenic nerve
The larger than usual head can be more

.
compressed than usual resulting in
Assess eyes for evidence of
increased intracranial pressure.
unresponsive or dilated pupils; assess for
Compression of the third, fourth, and sixth
vomiting, bulging fontanels, or a high-
cranial nerves limits eye response; other
pitched cry suggestive of increased
signs are additional signs of increased
intracranial pressure.
intracranial pressure.
Assess for activities such as jitteriness,

Seizures are yet another indication of
lethargy, and uncoordinated eye
increased intracranial pressure;
Cardiovascular Dysfunction
Polycythemia may occur in an LGA fetus as the fetus attempts to fully oxygenate
more than the average amount of body tissue. Following birth, observe LGA infants
closely for signs of hyperbilirubinemia that may result from absorption of blood from
bruising and breakdown of the extra red blood cells created by polycythemia.
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Hypoglycemia
LGA infants also need to be carefully assessed for hypoglycemia in the early hours
of life because large infants require large amounts of nutritional stores to sustain
their weight. If the mother had diabetes that was poorly controlled (the cause of the
large size), the infant would have had an increased blood glucose level in utero to
match the mother's glucose level; this caused the infant to produce elevated levels of
insulin. After birth, these increased insulin levels will continue for up to 24 hours of
life, possibly causing rebound hypoglycemia.
Nursing Diagnosis: Ineffective breathing pattern related to possible birth trauma in

the LGA newborn.
Outcome Evaluation: Newborn initiates independent breathing at birth; maintains

usual newborn respiratory rate of 30 to 60 breaths/min.
The Post term Infant

A post term infant is one born after the 41st week of a pregnancy (Rahimian,
2013). Infants who stay in utero past week 41 are at special risk because a placenta
appears to function effectively for only 40 weeks. After that time, it seems to lose its
ability to carry nutrients effectively to the fetus, and the fetus begins to lose weight
(post term syndrome). Infants with this syndrome demonstrate many of the
characteristics of the SGA infant: dry, cracked, almost leather like skin from lack of
fluid, and an absence of vermix. They may be SGA, and the amount of amniotic fluid
surrounding them may be less at birth than usual and it may be meconium stained.
Fingernails will have grown well beyond the end of the fingertips. Because they are
older than a term infant, they may demonstrate an alertness much more like a 2-
week-old baby than a newborn when a pregnancy becomes post term, a sonogram
1s usually obtained to measure the bi parietal diameter of the fetus. A non-stress test
or complete biophysical profile may be done to establish whether the placenta is still
functioning adequately.
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ILLNESSES THAT OCCUR IN NEWBORN
A number of illnesses occur specifically in newborns that automatically cause the

infant to be classified as high risk.
I. Respiratory Distress Syndrome
Respiratory distress syndrome (RDS) is a common problem in premature

babies. It causes babies to need extra oxygen and help with breathing
RDS occurs when there is not enough surfactant in the lungs. Surfactant is a
liquid made by the lungs that keeps the airways (alveoli) open. This liquid makes it
possible for babies to breathe in air after delivery. An unborn baby starts to make
surfactant at about 26 weeks of pregnancy. If a baby is premature (born before 37
weeks of pregnancy), he or she may not have made enough surfactant yet.
Risk Factors:
 boy or is white
 has a sibling born with RDS
 C-section (Cesarean) delivery, especially without labor
 doesn’t get enough oxygen just before, during, or after birth (perinatal
asphyxia)
 has trouble maintaining body temperature (cold stress)
 Infection
 twin or other multiple
 mother has diabetes
 the baby has a condition called patent ductus arteriosus (PDA)
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Sign/Symptoms:
 Breathing problems at birth that get worse

 Blue skin color (cyanosis)
 Flaring nostrils
 Rapid breathing
 Grunting sounds with breathing
 Ribs and breastbone pulling in when the baby breathes (chest retractions)
Diagnosis:
There's no specific test to identify ARDS. The diagnosis is based on the

physical exam, chest X-ray and oxygen levels. It's also important to rule out other
diseases and conditions.
Management:
Treatment will depend on your child’s symptoms, age, and general health. It
will also depend on how severe the condition is.
 Treatment for RDS may include:

 Placing a breathing tube into your baby's windpipe (trachea)
 Having a ventilator breathe for the baby
 Extra oxygen (supplemental oxygen)
 Continuous positive airway pressure (CPAP). This is a breathing machine that
pushes a continuous flow of air or oxygen to the airways. It helps keep tiny air
passages in the lungs open.
 Artificial surfactant. This helps the most if it is started in the first 6 hours of
birth. Surfactant replacement may help make RDS less serious. It is given as
preventive treatment for some babies at very high risk for RDS. For others
who become sick after birth, it is used as a rescue method. Surfactant is a
liquid given through the breathing tube.
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 Medicines to help calm the baby and ease pain during treatment
Prevention
Preventing a premature birth is the main way to prevent RDS. When a

premature birth can’t be prevented, you may be given corticosteroids before delivery.
These medicines may greatly lower the risk and severity of RDS in the baby.
II. Transient Tachypnea of the Newborn
Transient tachypnea of the newborn (TTN) is a benign, self-limited condition

that can present in infants of any gestational age shortly after birth. It is caused by a
delay in the clearance of fetal lung fluid after birth, which leads to ineffective gas
exchange, respiratory distress, and tachypnea.
Risk Factors:
 Maternal risk factors include delivery before completion of 39 weeks

gestation, a cesarean section without labor, gestational diabetes, and
maternal asthma.
 Fetal risk factors include male gender, perinatal asphyxia, prematurity,
small for gestational age, and large for gestational age infants.
 infants who delivered between 33 and 34 weeks, approximately 5%
between 35 and 36 weeks, and less than 1% in term infants.
 Sodium in the alveolus is transported passively across the ENaC proteins
which in turn is actively transported back to the interstitium by the Na+/K+-
ATPase pump.[11]
 An osmotic gradient is created which allows chloride and water to follow
and be absorbed into pulmonary circulation and lymphatics.
Sign/Symptoms:
 noisy breathing (grunting)

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 Tachypnea (respiratory rate greater than 60 per minute)

 Nasal flaring
 Intercostal/subcostal/suprasternal retractions
 Crackles, diminished or normal breath sounds on auscultation
 Tachycardia
 Cyanosis
 Barrel-shaped chest because of hyperinflation
Diagnosis:
 Chest x-ray
 Complete blood count (CBC) and blood cultures
Pneumonia, respiratory distress syndrome, and sepsis may have similar
manifestations, so chest x-ray, CBC, and blood cultures usually are done. Chest x-
ray shows normally inflated or hyperinflated lungs with streaky perihilar markings,
giving the appearance of a shaggy heart border while the periphery of the lungs is
clear. Fluid is often seen in the lung fissures.
If initial findings are indeterminate or suggest infection, antibiotics (eg,

ampicillin, gentamicin) are given while awaiting culture results.
Management:
Your baby will be given oxygen as needed to maintain an adequate blood

oxygen level. Pulse oximeter and/or blood gases may be used. Your baby’s oxygen
requirement will usually be highest within a few hours after birth and then begin to
decrease. Most infants with TTN improve in 12 to 24 hours.
If your baby is breathing very rapidly, feedings may be withheld and

intravenous fluids may be given for nutrition until he or she improves. Your baby may
also receive antibiotics during this time until infection is ruled out. Rarely, babies with
TTN may have persistent lung problems for as long as one wee
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Pudadera, Joseph
Sevilla, Shelallae
Prevention:
One of the keys in the prevention of TTN is limiting cesarean section

whenever possible, and planning elective cesarean deliveries, when deemed
necessary, at or after 39 weeks gestation.
III. Meconium Aspiration Syndrome
Meconium is the first feces, or stool, of the newborn. Meconium aspiration

syndrome occurs when a newborn breathes a mixture of meconium and amniotic
fluid into the lungs around the time of delivery. Meconium aspiration syndrome, a
leading cause of severe illness and death in the newborn. It typically occurs when
the fetus is stressed during labor, especially when the infant is past its due date.
Risk Factors:
 "Aging" of the placenta if the pregnancy goes far past the due date
 Decreased oxygen to the infant while in the uterus
 Diabetes in the pregnant mother
 Difficult delivery or long labor
 High blood pressure in the pregnant mother
Sign/Symptoms:
 Bluish skin color in the infant

 Breathing problems
 Dark, greenish staining or streaking of the amniotic fluid or the obvious
presence of meconium in the amniotic fluid
 Limpness in infant at birth
Diagnosis:
 Before birth, the fetal monitor may show a slow heart rate.
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 At birth, meconium can be seen in the amniotic fluid. The most accurate
test to check for possible meconium aspiration involves looking for
meconium staining on the vocal cords with a laryngoscope.
 Abnormal breath sounds, especially coarse, crackly sounds, are heard
through a stethoscope.
 A blood gas analysis shows low blood acidity, decreased oxygen and
increased carbon dioxide.
 A chest X-ray may show patchy or streaky areas on the lungs.
Management:
The newborn's mouth should be suctioned as soon as the head can be seen
during delivery. Further treatment is necessary if there is thick meconium staining
and fetal distress. The infant may be placed in the special care nursery or newborn
intensive care unit. Other treatments may include:
 Antibiotics to treat infection

 Breathing machine to keep the lungs inflated
 Use of a warmer to maintain body temperature
 Tapping on the chest to loosen secretions
If there have been no signs of fetal distress during pregnancy and the baby is
a vigorous full-term newborn, experts recommend against deep suctioning of the
windpipe for fear of causing a certain type of pneumonia.
IV. Apnea
Apnea is a pause in breathing that lasts 20 seconds or longer for full-term

infants. If a pause in breathing lasts less than 20 seconds and makes your baby's
heart beat more slowly (bradycardia) or if he turns pale or bluish (cyanotic), it can
also be called apnea.
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Risk Factor:
 Babies with secondary stresses

 Infection
 hyperbilirubinemia
 hypoglycemia, or hypothermia
Sign/Symptoms:
 temporary cessation of breathing

 an abnormal bluish discoloration of the skin, lips, and mouth (cyanosis)
 unusually slow heartbeat (bradycardia).
 serious apnea is defined as the cessation of breathing during sleep for longer
than 10 to 15 seconds.
Diagnosis:
 Clinical evaluation
 Cardiorespiratory monitoring
 Other causes (eg, hypoglycemia, sepsis, intracranial hemorrhage) ruled out
Although frequently attributable to immature respiratory control mechanisms,
apnea in premature infants can be a sign of infectious, metabolic, thermoregulatory,
respiratory, cardiac, or CNS dysfunction. Thorough history, physical assessment,
and, when necessary, testing should be done before accepting prematurity as the
cause of apnea. Gastroesophageal reflux disease ( GERD) is no longer thought to
cause apnea in preterm infants, so the presence of GERD should not be considered
an explanation for apneic episodes nor should treatment for GERD be started
because of apnea of prematurity.
Diagnosis of apnea usually is made by visual observation or by use of

impedance-type cardiorespiratory monitors used continuously during assessment
and ongoing care of preterm infants.
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Medicines
 Many babies with AOP are given oral or intravenous (IV) caffeine medicine to
stimulate their breathing. A low dose of caffeine helps keep them alert and
breathing regularly.
Monitoring Breathing
 Babies are watched continuously for any sign of apnea. The cardiorespiratory
monitor (also known as an apnea and bradycardia, or A/B, monitor) also
tracks the infant's heart rate. An alarm sounds if there's no breath for a set
number of seconds, and a nurse will immediately check the baby for signs of
distress.
 If the baby doesn't begin to breathe again within 15 seconds, the nurse will
rub the baby's back, arms, or legs to stimulate breathing. Most of the time,
babies will begin breathing again on their own with this kind of stimulation.
 A baby who still isn't breathing after being stimulated and is pale or bluish
might get oxygen through a handheld bag and mask. The nurse or doctor will
place the mask over the infant's face and use the bag to slowly pump a few
breaths into the lungs. Usually only a few breaths are needed before the baby
begins to breathe again on his or her own.
Prevention:
To help prevent episodes of apnea, maintain a neutral thermal environment

and use gentle handling to avoid excessive fatigue. Always suction gently and only
when needed to minimize nasopharyngeal irritation, which can cause bradycardia
because of vagal stimulation. Using indwelling nasogastric tubes rather than
intermittent ones can also reduce the amount of vagal stimulation.
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V . Sudden Infant Death Syndrome
Sudden infant death syndrome (SIDS) is a sudden unexplained death in

infancy. Researchers don't know the exact cause of SIDS. Studies have shown that
some babies who die from SIDS have the following: Problems with brain functioning,
Differences in genes, Problems with heart functioning and Infection
Risk Factor:
 underweight
 Preterm infants.
 infants with BPD
 twins
 Native American infants
 Alaskan Native infants
 infants of narcotic-dependent mothers.
 The peak age of incidence is 2 to 4 months of age
Sign/Symptoms:
There are no symptoms or warning signs of SIDS that can be used to prevent it.
Diagnosis:
The diagnosis of SIDS is made when the cause of death is unexplained after a full
investigation. An investigation includes:
 Examining the body after death

 Examining where the death took place
 Reviewing the baby’s symptoms or illnesses before death
 Any other related health history
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Management:
There is no specific treatment for SIDS.
Prevention:
Although there is no 100% way to prevent SIDS, there is a lot you can do to
lower your baby’s risk
 Put a Sleeping Baby on Their Back- risk of SIDS is much higher any time they
sleep on their side or stomach. (A baby placed on their side can roll over on
their stomach.)
 Firm Bed, No Soft Toys or Bedding- to prevent smothering or suffocation
 Don't Smoke around Your Baby- babies born to women who smoked during
pregnancy die from SIDS three times more often than babies born to
nonsmokers.
 Keep Your Sleeping Baby Close, but Not in Your Bed- When a baby sleeps in
the same room as mom, studies show it lowers the risk of SIDS. But it's
dangerous for a baby to sleep with another child or an adult in the same bed,
in an armchair, and on a couch.
 Breastfeed as Long as You Can- it can lower the risk of SIDS by as much as
50%, though experts aren't sure why. Some think breast milk may protect
babies from infections that raise their SIDS risk.
 Immunize Your Baby- babies who’ve been immunized in accordance with
recommendations from the American Academy of Pediatrics and the CDC
have a 50% reduced risk of SIDS compared with babies who aren’t fully
immunized.
 Consider Using a Pacifier to Put Baby to Sleep- Putting your baby to sleep
with a pacifier may also help prevent SIDS, though researchers aren't sure
why.
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 Keep Your Baby From Overheating- Because overheating may raise a baby's
risk of SIDS
 Steer Clear of Products That Claim to Reduce the Risk of SIDS- It's best to
avoid any product that says it can lower your baby's risk of SIDS, because
they haven't been proven safe or effective. Cardiac monitors and electronic
respirators also haven't been proven to reduce SIDS risk, so avoid these, too
 Don't Give Honey to an Infant under 1 Year Old- because honey can lead to
botulism in very young children, botulism and the bacteria that cause it may
be linked to SIDS.
VI. Apparent Life-Threatening Event
An apparent life-threatening event (ALTE) is an acute, unexpected episode in

an infant that is witnessed by and is frightening to a caregiver because of some
combination of apnea, color change, change in muscle tone, choking, or gagging.
Risk Factor:
 history of prematurity
 history of prior ALTE
 episodes of pallor
 cyanosis
 apnea
 common cold
 age less than 10 weeks.
Sign/Symptoms:
 apnea
 change in color
 change in muscle tone
 Coughing or gagging.
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Mangirapin, James
Nonan, Maria wena
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Pudadera, Joseph
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Diagnosis:
The most commonly cited diagnoses include gastroesophageal reflux (GER),

seizures, and lower respiratory tract infections. Because ALTE is a description rather
than a diagnosis, the hospitalist must consider the underlying cause. Many of the
diagnoses associated with ALTE are easy to differentiate on the basis of history and
physical examination.
Management:
 Criteria of admission
 Treatment for individual causes
 Education of caregivers
 Home monitoring
Prevention:
Education for Caregivers- All caregivers of infants with an ALTE should be informed
about preventative and emergency management (such as standard cardiopulmonary
resuscitation techniques)
Safe sleep position- (including the supine position, with the face free, in an
adequately heated room) and avoiding exposure to tobacco smoke will be beneficial
However, there is no evidence that apnea monitoring can prevent SIDS after
an ALTE. Routine monitoring of all infants with an ALTE is not generally
recommended. Although there are no accepted criteria to determine which patient
should be home monitored, some publications recommended home monitoring for
infants with an idiopathic ALTE or those who needed vigorous resuscitation.
VII. Periventricular Leukomalacia

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Pudadera, Joseph
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Periventricular leukomalacia (PVL) is a type of brain injury that affects

premature infants. The condition involves the death of small areas of brain tissue
around fluid-filled areas called ventricles. The damage creates "holes" in the brain.
"Leuko" refers to the brain's white matter. "Periventricular" refers to the area around
the ventricles.
Risk Factor:
 premature infants
 Babies who are more premature and more unstable at birth.
 Premature babies who have intraventricular hemorrhage (IVH)
Sign/Symptoms:
Every child with PVL is unique and will have his or her own set of symptoms,
which often become apparent over time as the child develops, rather than all at
once.
The most common symptoms of PVL are:
 trouble with vision and with eye movements

 trouble with movement, and tight muscles
 developmental delay that is increasingly apparent over time
Diagnosis:
Newborns may not show symptoms of PVL in the first few days of life.
However, since premature infants have an increased risk of developing the
condition, doctors may perform the following diagnostic tests:
 cranial ultrasound: a painless test that uses sound waves to view the baby's
brain through the soft spot on top of the head (fontanel)
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 Magnetic resonance imaging (MRI): this imaging procedure uses a magnetic

field and radio to produce a detailed picture of the brain without exposing the
infant to x-rays. PVL is a term that describes the way the affected infant’s
brain looks on an MRI
Management:
Although there is no treatment for PVL, we may recommend other types of care for
your child, such as:
 physical therapy
 occupational therapy
 speech-language therapy
 vision therapy
Prevention:
There is no treatment for PVL. Premature babies' heart, lung, intestine, and
kidney functions are watched closely and treated in the newborn intensive care unit
(NICU). This helps reduce the risk of developing PVL.
VIII. Hemolytic Disease of the Newborn (Hyperbilirubinemia)
Hemolytic disease of the newborn (HDN) is a blood problem in newborn

babies. It occurs when your baby's red blood cells break down at a fast rate. It’s also
called erythroblastosis fetalis.
Risk Factor:
 You’re Rh negative and have an Rh positive baby but haven’t received

treatment.
 You’re Rh negative and have been sensitized. This can happen in a past
pregnancy with an Rh positive baby. Or it can happen because of an injury or
test in this pregnancy with an Rh positive baby.
 HDN is about 3 times more common in white babies than in African-American
babies.
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Operana, Lexus
Pudadera, Joseph
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Sign/Symptoms:
Symptoms can occur a bit differently in each pregnancy and child. During pregnancy,
you won't notice any symptoms. But your healthcare provider may see the following
during a prenatal test:
 A yellow coloring of amniotic fluid. This color may be because of bilirubin. This
is a substance that forms as blood cells break down.
 Your baby may have a big liver, spleen, or heart. There may also be extra
fluid in their stomach, lungs, or scalp. These are signs of hydrops fetalis. This
condition causes severe swelling (edema).
After birth, symptoms in your baby may include:
 Pale-looking skin. This is from having too few red blood cells (anemia).
 Yellow coloring of your baby’s umbilical cord, skin, and the whites of their
eyes (jaundice). Your baby may not look yellow right after birth. But jaundice
can come on quickly. It often starts in 24 to 36 hours.
 Your newborn may have a big liver and spleen.
 A newborn with hydrops fetalis may have severe swelling of their entire body.
They may also be very pale and have trouble breathing.
Diagnosis:
To make a diagnosis, your child’s healthcare provider will look for blood types
that cannot work together. Sometimes this diagnosis is made during pregnancy. It
will be based on results from the following tests:
 Blood test- Testing is done to look for Rh positive antibodies in your blood.
 Ultrasound- This test can show enlarged organs or fluid buildup in your baby.
 Amniocentesis- This test is done to check the amount of bilirubin in the
amniotic fluid.
 Percutaneous umbilical cord blood sampling- This test is also called fetal
blood sampling. In this test, a blood sample is taken from your baby’s
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umbilical cord. Your child’s healthcare provider will check this blood for
antibodies, bilirubin, and anemia. This is done to check if your baby needs an
intrauterine blood transfusion.
The following tests are used to diagnose HDN after your baby is born:
 Testing of your baby's umbilical cord. This can show your baby’s blood group,
Rh factor, red blood cell count, and antibodies.
 Testing of the baby's blood for bilirubin levels.
Management:
During pregnancy, treatment for HDN may include the following.
 Monitoring- a healthcare provider will check your baby’s blood flow with an
ultrasound.
 Intrauterine blood transfusion- this test puts red blood cells into your baby's
circulation. In this test, a needle is placed through your uterus. It goes into
your baby’s abdominal cavity to a vein in the umbilical cord. Your baby may
need sedative medicine to keep him or her from moving. You may need to
have more than 1 transfusion.
 Early delivery- if your baby gets certain complications, they may need to be
born early. Your healthcare provider may induce labor may once your baby
has mature lungs. This can keep HDN from getting worse.
After birth, treatment may include the following.
 Blood transfusions- this may be done if your baby has severe anemia.
 Intravenous fluids- tthis may be done if your baby has low blood pressure
 Phototherapy- in this test, your baby is put under a special light. This helps
your baby get rid of extra bilirubin.
 Help with breathing- your baby may need oxygen, a substance in the lungs
that helps keep the tiny air sacs open (surfactant), or a mechanical breathing
machine (ventilator) to breathe better.
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 Exchange transfusion- his test removes your baby’s blood that has a high
bilirubin level. It replaces it with fresh blood that has a normal bilirubin level.
This raises your baby’s red blood cell count. It also lowers their bilirubin level.
In this test, your baby will alternate giving and getting small amounts of blood.
 Intravenous immunoglobulin (IVIG) - IVIG is a solution made from blood
plasma. It contains antibodies to help the baby's immune system. IVIG
reduces your baby’s breakdown of red blood cells. It may also lower their
bilirubin levels.
Prevention:
HDN can be prevented. Almost all women will have a blood test to learn their
blood type early in pregnancy.
If you’re Rh negative and have not been sensitized, you’ll get a medicine
called Rh immunoglobulin (RhoGAM). This medicine can stop your antibodies from
reacting to your baby’s Rh positive cells. Many women get RhoGAM around week 28
of pregnancy.
If your baby is Rh positive, you’ll get a second dose of medicine within 72

hours of giving birth. If your baby is Rh negative, you won’t need a second dose
IX. Twin to Twin Transfusion
Twin-to-twin transfusion syndrome (TTTS) is a rare pregnancy condition

affecting identical twins or other multiples. TTTS occurs in pregnancies where twins
share one placenta (afterbirth) and a network of blood vessels that supply oxygen
and nutrients essential for development in the womb. These pregnancies are known
as monochorionic.
Risk Factor:
Being pregnant with identical twins or multiples puts a woman at risk for
having a pregnancy complicated by TTTS. However, TTTS is an indiscriminate
condition, occurring at random in monochorionic pregnancies.
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Sign/Symptoms:
In many cases a mother may not experiences symptoms of TTTS. However,

some mothers whose twins have TTTS will feel signs of excess amniotic fluid,
including:
 A uterus that measures large for her stage of pregnancy

 Feeling like her abdomen is growing or expanding rapidly
 A sudden increase in body weight
 Increased abdominal pressure or pain
 Shortness of breath
 Uterine cramping or contractions
 Swelling of the hands and legs early in the pregnancy
Diagnosis:
TTTS is diagnosed by ultrasound. The earlier the disease is diagnosed

specifically when the disease is in its early stages the better the prognosis. And the
sooner we’re able to intervene ideally within hours of diagnosis the better the chance
is for a positive outcome.
If you're pregnant with monochorionic-diamniotic twins, we recommend you

are evaluated via ultrasound at least every two weeks throughout your pregnancy
once you reach 16 weeks into your pregnancy.
Management:
The treatments for TTTS pregnancies depend, in part, on when in pregnancy

the twins become affected. If the twins are mature enough to survive outside the
womb (beyond 25 weeks), immediate delivery is an option for TTTS babies.
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Fetoscopic Placental laser Therapy- since TTTS does not exist in identical
monochorionic (MC) twins without the connecting placental blood vessels, it seems
reasonable to find a way to separate the twins’
Amnioreduction- a procedure where a doctor removes the extra amniotic fluid in the
amniotic sac using a small needle with ultrasound guidance. The doctor will remove
fluid until a mother's fluid levels return to normal. Blood streams by destroying the
connections.
Prevention:
TTTS is caused by abnormal connections between twins that form when the
placenta first develops. This is a purely mechanical and random event that can’t be
avoided. “The mother can do absolutely nothing to prevent it,” says Dr. Norman
Davies
X. Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) is a serious gastrointestinal problem that

mostly affects premature babies. The condition inflames intestinal tissue, causing it
to die.
A hole (perforation) may form in your baby's intestine. Bacteria can leak into
the abdomen (belly) or bloodstream through the hole. NEC usually develops within
two to six weeks after birth.
In some infants, NEC is mild. Others experience severe, life-threatening

symptoms.
The different types of NEC include:
 Classic- this most common type of NEC tends to affect infants born before 28
weeks of pregnancy. Classic NEC occurs three to six weeks after birth. In
most instances, the baby is stable and doing well. Then the condition comes
on suddenly, without warning.
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 Transfusion-associated- an infant may need a blood transfusion to treat

anemia (lack of red blood cells). About 1 in 3 premature babies develop NEC
within three days of getting a blood transfusion
 Atypical- rarely, an infant develops NEC in the first week of life or before the
first feeding.
 Term infant- full-term babies who get NEC usually have a birth defect.
Possible causes include congenital heart condition, gastroschisis (intestines
that form outside of the body) and low oxygen levels at birth.
Risk Factor:
 Premature Newborn
 Term Infant with pre-existing illness
 Fed through a tube in the stomach (enteral nutrition).
 Weighing less than 5 1/2 pounds at birth.
Symptoms:
 abdominal pain and swelling

 changes in heart rate, blood pressure, body temperature and breathing
 diarrhea with bloody stool
 green or yellow vomit
 lethargy
 refusing to eat and lack of weight gain
Diagnosis:
Your healthcare provider will examine your baby. They check for a swollen belly and
other NEC symptoms.
Your provider may also order these tests:
 Blood tests: A blood test checks for bacteria and other signs of infection.
 Fecal test: This test checks for blood in your baby’s poop. It can detect blood
that isn’t visible.
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 X-rays: Abdominal X-rays can show signs of NEC, including air bubbles (gas)
around the intestine or abdominal cavity. Air bubbles can indicate a damaged
bowel or perforation.
Management:
Your baby’s intestines need time to rest and heal. The first step in treating
NEC is to stop tube or oral feedings. Instead, your baby receives intravenous (IV)
fluids and nutrients.
Your baby may also get these treatments:
 Nasogastric tube: Your provider inserts a long, thin tube through the nose (or
sometimes the mouth). The tube goes into the stomach to suction out gas and
fluids.
 Antibiotics: Antibiotics help fight bacterial infections.
About 1 in 4 babies need surgery to remove dead intestinal tissue and
repair a hole. Your child’s provider may perform an ostomy procedure. This
surgery:
 Creates a small hole (stoma) in the child’s belly.

 Connects the large intestine to the stoma.
 Allows poop to exit the body through the stoma into a bag outside of the body.
When your baby is stronger, your provider will reattach the intestines
and replace them in the abdomen.
Prevention:
If you are at risk for a preterm birth, you may get corticosteroid injections. This
medication boosts an unborn baby’s health. It may lower your baby’s chances of
lung and intestinal problems.
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Feeding an infant breast milk may lower the risk of NEC. Some studies
suggest that adding probiotics (healthy bacteria) to breastmilk or formula also helps.
XI. Retinopathy of Prematurity
Retinopathy of prematurity, or ROP, occurs when blood vessels in a baby's

eye develop abnormally. ROP affects the retina, the tissue that lines the internal
surface of the back of the eye and transmits visual information to the brain. In order
to function properly, the retina requires a blood supply. While a baby is developing
inside the womb, blood vessels grow that provide blood to the retina. This growth is
usually completed a few weeks before birth. When a baby's born prematurely, the
blood vessels of the retina haven't yet fully developed. As a result, the vessels may
develop abnormally after birth.
Risk Factor:
 Premature Babies
Symptoms:
Subtle changes in a baby's retina aren't easily detected and can't be seen by
parents or pediatric doctors and nurses. Only a pediatric ophthalmologist, a doctor
who specializes in eye care, can detect signs of retinopathy of prematurity by using
special instruments to examine the baby's retina.
Severe and untreated ROP may cause some of the following symptoms:
 White pupils, called leukocoria

 Abnormal eye movements, called nystagmus
 Crossed eyes, called strabismus
 Severe nearsightedness, called myopia
Diagnosis:
All premature babies who may be at risk for ROP are carefully monitored and
examined for the condition beginning a few weeks after birth, before they're
discharged from the hospital. The only way to determine if babies have ROP is to
examine the inside of their eyes for abnormalities in the retina.
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Ophthalmologists trained in the diagnosis and treatment of ROP will examine

your baby's eyes. During this exam, your baby's pupils will be dilated with eye drops
so the retina can be studied. If any signs of ROP are detected, follow-up evaluations
will be recommended over the following weeks.
ROP is defined by different stages, based on the severity of the disease. In

mild cases, the baby's retinal blood vessels may continue to grow normally, and
treatment isn't required. In more severe cases, there are noticeable abnormalities in
the development of the retinal blood vessels that, in the most severe cases, can lead
to detachment of the retina and blindness. This occurs rarely and only in the most
severely affected infants.
Management:
Treatment for ROP depends on the stage and severity of the condition. The milder
stages of the disease typically resolve by themselves, and don't require treatment.
However, if the disease has progressed to a point where your baby's vision is at risk,
treatment is needed.
The most common treatment is laser photocoagulation, in which a laser is

directed to a specific spot to destroy abnormal blood vessels and seal leaks. Laser
photocoagulation involves little postoperative pain and swelling.
Prevention:
Prevention of ROP must start with optimizing the oxygen delivery to

minimizing the vessel loss and vessel growth cessation that set the stage for
proliferative ROP. However, oxygen must also be optimized to prevent the brain
damage and death.
Lecture Summary
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The vast majority of newborns enter the world healthy. But sometimes, infants
develop conditions that require medical tests and treatment. Newborns are
particularly susceptible to certain diseases, much more so than older children and
adults. Their new immune systems aren't adequately developed to fight the bacteria,
viruses, and parasites that cause these infections. As a result, when newborns get
sick, they may need to spend time in the hospital or even the neonatal intensive care
unit (NICU) to recover. Although it can be frightening to see your baby hospitalized, a
hospital stay is often the best way back to good health for a sick newborn.
THE NEWBORN AT RISK BECAUSE OF MATERNAL INFECTION
New-borns are susceptible to infections during pregnancy and at birth because their
ability to produce antibodies is immature.
β-Hemolytic, Group B Streptococcal Infection
A serious cause of infection in new-borns is the gram-positive β-hemolytic, group B

streptococcal (GBS) organism, a natural inhabitant of the female genital tract. It also
may be spread from baby to baby if good hand washing technique is not used in
caring for new-borns. If a woman is found to be positive for GBS during late
pregnancy, ampicillin administered IV during pregnancy and again during labor helps
to reduce the possibility of new-born exposure.
Assessment:
Universal screening is recommended for pregnant women at 35 to 37 weeks of

gestation to see if they have GBS organisms in their vaginal secretions. Typically, a
new-born at risk, such as one born after prolonged rupture of membranes or if the
woman’s vaginal culture is positive for GBS, will be screened at birth for infection by
a specialized GBS blood culture.
Colonization by GBS can result in either an early-onset or a late-onset illness. With

the early-onset form, signs of pneumonia such as tachypnea, apnea, extreme
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paleness, hypotension, or hypotonia become apparent within the first day of life.
Without therapy, the disease progresses so rapidly, as many as 20% of infants who
contract the infection die within 24 hours of birth.
A late-onset type occurs at 2 to 4 weeks of age. With this, instead of pneumonia

being the infection focus, meningitis tends to occur. Typical signs include lethargy,
fever, loss of appetite, and bulging fontanelles from increased intracranial pressure.
Mortality from the late-onset type is not as high as that from the early-onset form
(15% vs. 20%), but neurologic consequences can occur in up to 50% of infants who
survive.
Therapeutic Management:
Antibiotics such as penicillin, cefazolin, clindamycin, or vancomycin are all effective

against the GBS organism. Parents may have difficulty understanding how their
infant could suddenly have become this ill, and they may need a great deal of
support to care for their infant. In the future, immunization of all women of
childbearing age against streptococcal B organisms could decrease the incidence of
newborns infected at birth.
Ophthalmia Neonatorum
Ophthalmia neonatorum is an eye infection that occurs at birth or during the first
month of life. The most common causative organisms are Neisseria gonorrhoeae
and Chlamydia trachomatis, which are contracted from vaginal secretions. An N.
gonorrhoeae infection is an extremely serious form of infection because, if left
untreated, the infection progresses to corneal ulceration and destruction, resulting in
opacity of the cornea and severe vision impairment.
Assessment:
Ophthalmia neonatorum is generally bilateral. The conjunctivae become fiery red

and covered with thick pus. The eyelids appear edematous.
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Prevention:
The prophylactic instillation of erythromycin ointment into the eyes of newborns

prevents both gonococcal and chlamydial conjunctivitis. Now it is more customary to
delay the administration of the ointment until after the first reactivity period so the
newborn can clearly see the parents during this important attachment period.
If gonococci are identified, intravenous ceftriaxone (Rocephin) and penicillin are

effective drugs. If Chlamydia is identified, an ophthalmic solution of erythromycin is
commonly used. Sterile saline solution lavage to clear the copious discharge from
the eyes may be prescribed. Direct the stream of the irrigation fluid laterally so it
does not enter and contaminate the other eye.
The mother of the infected infant needs treatment for gonorrhea or chlamydia before
fallopian tube sterility or pelvic inflammatory disease can result. With either infection,
parents can be assured with early diagnosis and treatment that the prognosis for
normal eyesight in their child is good.
Hepatitis B Virus Infection
Hepatitis B virus (HBV) can be transmitted to the newborn through contact with
infected vaginal blood at birth when the mother is positive for the virus. Hepatitis B is
a destructive illness with greater than 90% of infected infants becoming chronic
carriers of the virus as well as the risk of developing liver cancer later in life.
If the mother is identified as HBsAg+, her infant should be bathed as soon as

possible after birth to remove HBV-infected blood and secretions. Gentle suctioning
is necessary to avoid trauma to the mucous membrane, which could allow HBV
invasion. To further protect against infection, the infant is administered serum
hepatitis B immune globulin (HBIG) in addition to the HBV vaccination. Although the
virus is transmitted in breast milk, once immune globulin has been administered,
women may breastfeed without risk to an infant.
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Generalized Herpesvirus Infection
A herpes simplex virus type 2 (HSV-2) infection can be contracted by a fetus across
the placenta if the mother has a primary infection during pregnancy. More often,
however, the virus is contracted from the vaginal secretions of a mother who has
active herpetic vulvovaginitis at the time of birth.
Assessment:
If the infection was acquired during pregnancy, an infant may be born with vesicles
covering the skin. The long-term prognosis of the child is guarded because severe
neurologic damage may have occurred simultaneously with the development of the
lesions. If infants don’t acquire the infection until birth, by day 4 to day 7 of life, they
show a loss of appetite, perhaps a low-grade fever, and lethargy. Stomatitis or a few
vesicles on the skin appear. Herpes vesicles always cluster, are pinpoint in size, and
are surrounded by a reddened base. After the vesicles appear, infants become
extremely ill. They develop dyspnea, jaundice, purpura, convulsions, and
hypotension. Death may occur within hours or days.
To confirm the diagnosis, cultures are obtained from representative vesicles as well
as from the nose, throat, anus, and umbilical cord. Blood serum is analyzed for IgM
antibodies.
An antiviral drug such as acyclovir (Zovirax), a drug that inhibits viral DNA synthesis,
is effective in combating this overwhelming infection. Antenatal antiviral prophylaxis
reduces viral shedding and recurrences at birth and reduces the need for cesarean
birth. Women with active herpetic vulvar lesions are advised to have cesarean birth
rather than vaginal birth to minimize the newborn’s exposure. Infants with an
infection should be separated from other infants in a nursery. Healthcare personnel
who have herpes simplex infections should not care for newborns until the lesions
are crusted. Urge a woman who is separated from her newborn at birth to view her
infant from the nursery window and participate in planning care to aid bonding.
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HIV Infection
HIV infection and AIDS can be caused by placental transfer or direct contact with
maternal blood during birth. The virus acts by attacking the lymphoreticular system,
in particular CD4-bearing helper T lymphocytes. There is no effective way to destroy
the HIV, so it remains in the body for life and can activate if the immune system
becomes depressed.
Transmission:
HIV infection is spread by exposure to blood and/or other body secretions through
perinatally from mother to fetus, and possibly through breastfeeding. Although it is
decreasing in incidence, the transmission of HIV from mother to child by placental
spread is still the most common reason for childhood HIV infection in the United
States.
Assessment:
The disorder appears to progress more rapidly in children and infants, however, who
receive the virus via placental transmission (if mothers do not receive treatment).
These children are usually HIV positive by 6 months and develop clinical signs of the
disease by 1 to 3 years of age. All infants born to infected mothers test positive for
antibodies to the virus at birth because of passive antibody transmission (which
persists for about 18 months).
Because of advances in general health care, increased birth control education

focused on the needs of women who are HIV positive as well as the availability of
antiretroviral medications, the number of infants born with HIV infection is
decreasing. Those infants who are born with HIV, once thought to have a short life
expectancy, now have an opportunity for long-term survival.
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THE NEWBORN AT RISK BECAUSE OF MATERNAL ILLNESS AN INFANT OF A

WOMAN WHO HAS DIABETES MELLITUS
- Infants of women who have diabetes mellitus whose illness was poorly
controlled during pregnancy are typically longer and weigh more than other babies
(macrosomia).
-The baby also has a greater chance of having a congenital anomaly such as
a cardiac anomaly because hyperglycemia is teratogenic to a rapidly growing fetus.
-Most such babies have a cushingoid (i.e., fat and puffy) appearance. They
tend to be lethargic or limp in the first days of life as a result of hyperglycemia. The
macrosomia results from overstimulation of pituitary growth hormone and extra fat
deposits created by high levels of insulin during pregnancy.
-This infant’s large size is deceptive, however, because, like all LGA babies,
they are often immature. RDS occurs at a higher rate than usual in these infants
because they may be born preterm or, if born at term, lecithin pathways may not be
mature.
-High fetal insulin secretion during pregnancy to counteract the hyperglycemia
can interfere with cortisol release. This could block the formation of lecithin and
further prevent lung maturity (Murphy, Janzen, Strehlow, et al., 2013).
-A term frequently used for these infants is “fragile giant.”
- An infant of a woman with diabetes loses a greater proportion of weight in the first
few days of life than does the average newborn because of the loss of extra fluid
accumulated.
-Observe such an infant closely to be certain this weight loss actually
represents a loss of extra fluid and that dehydration is not occurring
Complications
-A macrosomic infant has a greater chance of birth injury, especially shoulder
and neck injury. A cesarean birth may be necessary to avoid cephalopelvic
disproportion. Immediately after birth, the infant tends to be hyperglycemic because
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the mother was at least slightly hyperglycemic during pregnancy and excess glucose
transfused across the placenta.
-During pregnancy, the fetal pancreas responded to this high glucose level
with islet cell hypertrophy, resulting in matching high insulin levels.
-After birth, as an infant’s glucose level begins to fall because the mother’s
circulation is no longer supplying glucose, the overproduction of insulin will cause the
development of severe hypoglycemia.
-Hyperbilirubinemia also may occur in these infants because, if immature,
they cannot effectively clear bilirubin from their system. Hypocalcemia also
frequently develops because parathyroid hormone levels are lower in these infants
due to hypomagnesemia from excessive renal losses of magnesium. Although
infants of women with diabetes are usually LGA, an infant born to a woman with
extensive blood vessel involvement may be SGA because of poor placental
perfusion. The problems of hypoglycemia, hypocalcemia, and hyperbilirubinemia
remain the same.
Therapeutic Management
- In a newborn, hypoglycemia is defined as a serum glucose level of less than 45
mg/dl. To avoid a serum glucose level from falling this low, infants of women with
diabetes need to be fed early; if they are unable to suck, a continuous infusion of
glucose can be prescribed. It is important the infant not be given only a bolus of
glucose; otherwise, rebound hypoglycemia (accentuating the problem) can occur.
Some infants of women with diabetes have a smaller than usual left colon,
apparently another effect of intrauterine hyperglycemia, which can limit the amount
of oral feedings they can take in their first days of life.
- Signs of an inadequate colon include vomiting or abdominal distention after the first
few feedings. Careful monitoring for any vomiting and normal bowel movements can
help identify this condition.
An Infant of A Drug-Dependent Mother

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- Infants of drug-dependent women tend to be SGA. If the woman took a drug close
to birth, her infant may show withdrawal symptoms (neonatal abstinence syndrome)
shortly after birth.
These include such signs as:
 Irritability
 Disturbed sleep pattern
 Constant movement, possibly leading to abrasions on the elbows, knees, or
nose
 Tremors
 Frequent sneezing
 Shrill, high-pitched cry
 Possible hyperreflexia and clonus (neuromuscular irritability)
 Convulsions
 Tachypnea (rapid respirations), possibly so severe that it leads to
hyperventilation and alkalosis
 Vomiting and diarrhea, leading to large fluid losses and secondary
dehydration
-Specific neonatal abstinence scoring
tools can be used to quantify and
assess an infant’s status. When
symptoms begin to appear and when
they fade varies with the drug
involved, but, on average, symptoms
occur in 24 to 48 hours and last about
2 weeks.
-The infants of women who were on
methadone maintenance during
pregnancy will show the same
beginning and length of symptoms.
The abstinence sequence for the cocaine-addicted neonate is usually milder, but
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factors such as maladaptive coping behaviors may be present in such newborns into
preschool (Buckingham-Howes, Berger, Scaletti, et al., 2013).
- Narcotic metabolites or quinine (heroin is often mixed with quinine) may be
obtained from an infant’s urine or meconium in the first hour after birth to establish
that the drug was transferred into the infant before birth.
An Infant with Fetal Alcohol Exposure

-Alcohol crosses the placenta in the same concentration as is present in the
maternal bloodstream so may result in fetal alcohol exposure, or fetal alcohol
spectrum disorder (Tsai, Manchester, & Elias, 2012). The disorder appears in about
2 out of 1,000 newborns and is often more difficult to document than recreational
drug exposure because alcohol abuse may be more difficult to document. Because
alcohol has serious deteriorating effects on the placenta and it is unknown if there is
a safe threshold of alcohol ingestion during pregnancy, all pregnant women are
advised to avoid alcohol intake to prevent any teratogenic effects on their newborn
(Dunney, Muldoon, & Murphy, 2015).
-A newborn with fetal alcohol spectrum disorder has several possible
problems at birth. Characteristics that mark the syndrome include prenatal and
postnatal growth restriction; central nervous system involvement such as cognitive
challenge, microcephaly, and cerebral palsy; and a distinctive facial feature of a short
palpebral fissure and thin upper lip.
- During the neonatal period, an infant may appear tremulous, fidgety, and irritable
and may demonstrate a weak sucking reflex. Sleep disturbances are common, with
the baby tending to be either always awake or always asleep depending on the
mother’s alcohol level close to birth. The most serious long-term effect is cognitive
challenge.
-Behavior problems such as hyperactivity may occur in school-age children.
Growth deficiencies may remain throughout life. An infant needs conscientious
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follow-up so any future problems can be discovered. The mother needs a follow-up
to see if she can reduce her alcohol intake for better overall health (Cook, Green,
Lilley, et al., 2016)
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Nursing Care of A Family With High-Risk Newborn

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NURSING CARE OF A FAMILY WITH HIGH-RISK NEWBORN

On completion of this chapter, the reader will be able to:

 Describe the assessment of a newborn exposed to harmful drugs in utero

 Plan developmentally appropriate care for the high risk infant.

 Discuss the identification and care of infants with an inborn error of

 Identify clinical manifestations of infection in the newborn

Continuing assessment of high-risk infants involves the use of technology and

NEWBORN PRIORITIES IN THE FIRST DAYS OF LIFE

3. Maintenance of fluid and electrolyte balance

Indications a newborn is having difficulty making the transition from intrauterine to

Initiating and Maintaining Respirations

quickly and so may become hypoglycemic, compounding the initial problem even

Common Factors That Predispose Infants to Respiratory Difficulty and So May

Factors Predisposing Infants to Respiratory Difficulty in the First Few Days of

If a newborn infant does not initiate spontaneous breathing following gentle

IN MOST NEWBORNS, MECHANICAL SUCTIONING IS NOT NECESSARY, BUT

Suctioning a newborn with mechanical suction controlled by a finger valve. The

pressures of 15 to 20 cm H2O are generally adequate to continue.. (Wyckoff et al.,

THE PRESSURE FROM ANESTHESIA BAGS IS CONTROLLED SOLELY BY THE

Types of ventilation bags used in neonatal resuscitation.

Establishing Extrauterine Circulation

Maintaining Fluid and Electrolyte Balance

rate of fluid administration conscientiously in high-risk infants. Monitor fluid status

Radiant Heat Sources

measured, should be 95.9° to 97.7°F (35.5° to 36.5 °C). If an infant's temperature

Establishing Adequate Nutritional Intake

swallow air, such as those with a tracheoesophageal fistula awaiting surgery; or

Establishing Waste Elimination

Establishing Parent–Infant Bonding

Anticipating Developmental Needs

Follow-Up of the High-Risk Infant at Home

High-Risk Infants and Child Maltreatment

THE NEWBORN AT RISK BECAUSE OF ALTERED GESTATIONAL AGE OR

Infants need to be evaluated as soon as possible after birth to determine their

• Extremely-low-birth-weight (ELBW) infant: one weighing less than 1,000 g at

The Preterm Infant

Characteristics between Small-For-Gestational-Age and Preterm Infants

Birth weight <10th percentile Normal for age

Congenital Strong possibility Possibility

Pulmonary Meconium aspiration, Respiratory distress

problems most pulmonary hemorrhage, syndrome

apt to occur pneumothorax

Hyperbilirubinemia Possibility Very strong possibility

Hypoglycemia Very strong possibility Possibility

Intracranial Strong possibility Possibility

Apnea episodes Possibility Very strong possibility

Feeding problems Most likely because of Small stomach capacity;

Weight gain in Rapid Slow

Future restricted Possibly always be Not likely to be

growth <10th restricted in growth

percentile because of because “catch-up”

poor growth occurs

Common Factors Associated With Preterm Birth

• Poor nutritional status

On gross inspection, a preterm infant’s head appears disproportionately large (≥3 cm

An immature newborn at birth. (Photodisc/PunchStock.)

Acute Bilirubin Encephalopathy

Persistent Patent Ductus Arteriosus

A long-term effect of hemorrhage may be the development of hydrocephalus if there

Other Potential Complications

Nursing Diagnoses and Related Interventions