High Risk Newborn

during this lecture will be discussing the high-risk newborn it's kind of a neat part of the course because you can begin to put everything together here you can incorporate what was normal in the normal transition for the normal newborn and also so far would you learned about the high-risk pregnancy labor and delivery process and how that affects the newborn so you will be able to kind of put a lot of the puzzle pieces together during this lecture some of the topics we'll be discussing in the high-risk newborn lecture include inner uterine growth restriction large for gestational age just the opposite there the newborn of the diabetic mother hypoglycemia prematurity post maturity the newborn of the substance-abusing mother respiratory problems cold stress and jaundice there are several risk factors for having a newborn who is at higher risk for mortality or morbidity this means for death or greater risk for illness these include low socioeconomic status no prenatal care exposure to teratogens or teratogen so here that pronounced both ways what's that if you'll recall that exposure to environmental hazards these can be things that the mother has no control over or things like illicit drug use pre-existing maternal conditions heart disease hyperthyroidism hypertension or kidney disease age and pair and parity certainly mothers who are very young and mothers over 35 or greater risk for having a high-risk newborn and those who have had more than five children do you remember what that's called it's grand Multipure eighty and mothers who have had pregnancy complications such as placental abruption placenta previa oligo hi dream Neos which is low fluid level if you remember preterm labor this is Labor prior to 37 two weeks or prior to 38 weeks premature rupture of membranes to remember that's when the membranes rupture more than 24 hours prior preeclampsia and uterine rupture so these all place the newborn at high risk high risk for what mortality and morbidity so again morbidity is being more susceptible to illness mortality is more susceptible to death during the first 28 days we'll start this discussion with considering intrauterine growth restriction IUGR small-for-gestational-age SGA means that a baby weighs less than the 10th percentile for its weight given its gestational age so if you consider 100 babies at 38 weeks for example this baby would weigh less than the 10th percentile so 90 out of 100 babies is the same just a tional age way more than this one that indicates small-for-gestational-age intrauterine growth restriction is where there's advanced gestational age with limited fetal growth if you look at the picture here if the baby on the right were average weight for its gestational age baby on the left is interview during growth restricted you can see it's quite a difference here looking at these two considering they're both the same 2 station age there are two types of intrauterine growth restriction one is symmetrical or purported also as the name indicates the growth throughout the entirety of the baby is growth restricted so there's a restriction of growth in the size of organs body length and the head circumference this is generally due to long term conditions and often we can see this on ultrasound you at the beginning of the second trimester so not even half of the pregnancy is over with and we can see an ultrasound that there is intrauterine growth restriction this is symmetrical so if you look the entirety of the baby seems to be growth restricted the other type of classification for interview during growth restriction is asymmetrical or disproportional so if you think of this the birth weight is still less than the 10th percentile however its disproportional the head and/or body lengths remain normal often this is due to impaired utero Posehn total blood flow so at the start of the pregnancy there doesn't appear to be a problem to the head and/or body length remain normal and continue to grow normally however it's not until about the third trimester typically that we can see a symmetrical or disproportional interview during growth restriction being small-for-gestational-age or having intrauterine growth restriction does come with some complications for these newborns one of them is fetal hypoxia so the small produce a tional age infant is often chronically lower and oxygen levels in utero because of placental insufficiency so this gives them little reserve through the process of birth a little reserved to deal with low oxygen levels so they may have some hypoxia issues when they're born what kind of decelerations do you think you might see if there's hypoxia or your door open insufficiency we may be seeing some late decelerations also there greater risk for aspiration syndrome they may because of stress have a bowel movement the meconium prior to delivery they may go through stress relax their anal sphincter have meconium stool prior to delivery and aspirate on this their higher risk for hypothermia so if you think back to the normal newborn lecture how do newborns keep warm they have the brown fatty layer and certainly they're small for gestational age or have growth restriction they have less brown fat however they are term hopefully keeping a flexed position will help control some of this however they do have less fat stores in addition a complication is hypoglycemia so if they have an increased metabolic rate because they have heat loss and so on their greater risk for hypoglycemia low blood sugar level levels sometimes an SGA or IUGR babies will also see polycythemia what is polycythemia polycythemia is having a great number of immature red blood cells and this is in response to stress the definition for large for gestational age LGA is when an infant weighs more than the 90th percentile for its gestational age so that is out of a hundred babies of the same gestational age this baby weighs more than ninety of them so it's in the top ten percentile correlations if you think about this think back to the high-risk pregnancy module what do you think a correlation would be well huge one would be the diabetes if you'll recall the baby is not diabetic the mother has excess glucose high blood sugar levels the baby is not diabetic so it has the insulin and it then stores that glucose and becomes larger if you look at the picture here the baby on the right is large rotational age the baby on the Left is average gestational age also genetic potential larger parents make more larger babies multi-paradigm another correlation so women who have had more children have greater risk for having larger babies and male infants are sometimes larger than their female counterparts complications of the LG a newborn for the mother and newborn include birth trauma certainly if it's large for gestational age there may be greater chance for mal presentation or shoulder dystocia in addition on delivery there may be a fractured clavicle brachial plexus some kind of nerve palsy skull fractures cephalo hematoma intracranial hemorrhage all of these would be related to birth trauma because the baby is large for gestational age also there's an increased chance for induction of labour because the baby is big sometimes if they see this on ultrasound the provider and patient will decide to induce labor and there's a greater chance for cesarean section also because the baby is larger hypoglycemia this could be related to the diabetic mother polycythemia and hyper viscosity of the blood the newborn of a diabetic mother may be small for gestational age or large for gestational age those coming from a mother who has diabetes that's been associated with real problems retinal problems cardiac or vascular disease may give birth to a baby who is SGA or why if we think about the things that go along with vascular disease and the other problems I had mentioned here we have the sugar settling in the micro vasculature that would also prevent blood oxygen nutrients in that placental area would prevent the baby from getting those things so that baby could be small-for-gestational-age a baby could also be larger for gestational age if it's coming from a diabetic mother here a mother she has high blood glucose levels the baby is also exposed to those high blood glucose levels again as I've stated several times the baby is not a diabetic it has the insulin therefore it goes through the process when exposed to the high blood sugar levels and eventually will store this and become large for its decisional age so which is more common certainly LGA is more common than SGA is large for gestational age is more common you will see them as a rule of thumb if a baby is large for gestational age they will get a blood sugar on the baby to see because typically as I mentioned before are concerned with its blood sugar if it's large for gestational age it's coming from a diabetic mother is is this baby producing high insulin levels expecting high blood sugar levels when the cord is cut it's no longer exposed to the high blood sugar levels however it still has those high insulin levels so what do you think is blood sugar might do it might drop its blood sugar so that's the concern here with these LGA babies and babies of diabetic mothers what is it's blood sugar going to do also do you think it's going to behave like an older baby no it's going to behave like it would given it to just a tional age so fits born at 32 weeks it will act like a 32 week or even if it is larger than that complications of the newborn born to a diabetic mother include hypoglycemia what is hypoglycemia for baby this would be a blood sugar level of less than 45 milligrams per deciliter also hypocalcemia this can be related to being born early and also the mother's lab values hyperbilirubinemia or high bilirubin levels which can be associated with jaundice babies born to a diabetic or at higher risk for hyperbilirubinemia because they have less fluid so they have higher counts in addition there's often more trauma associated with their birth resulting in greater breakdown of these cells with the immature liver this will result in hyperbilirubinemia they often have more birth trauma as we've discussed so greater risk for shoulder dystocia greater risk for cephalo pelvic disproportion where they're too big for the mothers pelvis so this can result in some birth trauma they can have polycythemia higher numbers of immature red blood cells and this is because they need more oxygen in utero therefore this results in hypoxia is a compensatory mechanism the body produces more red blood cells so we will see a high number of immature red blood cells these babies are greater risk for respiratory distress syndrome because the ls lecithin bingo Milan and the PG factors are affected by the mother being diabetic in addition there are greater risk for congenital malformations these can include ventricular septal defect left or right ventricular wall hypertrophy colon issues kidney issues so there can be quite a host of things here that are complications for the baby of a diabetic mother hypoglycemia in reviewing the last slide what is hypoglycemia or a baby again this is a blood sugar level of less than forty five milligrams per deciliter and this will vary institution to institution but as a rule of thumb that's a good one signs and symptoms when might you think that a baby is hypoglycemic if you see tremors or in very severe cases seizures if the baby is ethnic what does apnea mean this is where it would be holding its breath now it's normal for a baby to breathe kind of irregularly but if you see that it's kind of forgetting to breathe it's having episodes of apnea where it's holding its breath or cyanosis during blue temperature instability poor feeding if the blood sugar becomes too low you'll see that it's too kind of tuckered out doesn't even have the energy to eat so you may see poor feeding and hypotonia lack of tone with a hypoglycemic baby what are the nursing implications we would expect it with babies large or gestational age to get a blood sugar at about an hour of life what do we do a blood sugar is less than 45 milligrams per deciliter we would want to feed the baby if the baby is unable to eat perhaps it's too small perhaps it doesn't want to eat and we can't force it to eat perhaps it's so glice hypoglycemic that it cannot eat we would expect an IV of dextrose solution to be administered to the baby we will then recheck blood sugars after the feeding to see what the blood sugar level is again this would be ordered on the individual baby by the provider however this is a general rule of thumb for a larger gestational age baby we would check it in an hour and if it's less 45 we would feed the baby we want to get the blood sugar back up again so we'll feed the baby if it's breast feeding will encourage the mother to put the baby to breast to get colostrum if it's bottle eating we would expect that in scenarios the baby cannot eat or will not eat where the blood sugar level does not come up adequately we may see an order for a dextrose solution IV a premature baby is a baby who is born preterm so we talked about a pregnancy being term when it is between 38 and 42 weeks gestation so preterm would be when it's delivered prior to 38 weeks the book says prior to 37 completed weeks so this means preterm would be up to and including 37 weeks and six days note that in the clinical setting some clinical places will say 36 weeks is term we will be using the textbook definition of 38 weeks or 37 completed weeks for the definition for preterm the incidence is about 12% of deliveries certainly if you're at a tertiary care center you will be seeing this more than you would at a level 1 or less risky kind of facility the concern here is essentially all of the body systems or premature and we'll talk about how this affects many of the body systems so this makes the transition to extra uterine life even more complex we talked about the normal newborn lecture the complexities associated with a baby going from kind of the fetal intrauterine state where the placenta and the mother's body is doing much for the fetus now this preterm baby is expected to go through all those extra uterine life changes with immature body systems so starting with the cardiovascular and respiratory systems a premature baby is a great risk for respiratory distress syndrome RDS this is an issue because there's an inadequate amount of surfactant and surfactants it what is used for lung compliance you can kind of blow up those alveolar sacs and the lungs also the pulmonary vessels aren't fully developed so the musculature in the fold and the pulmonary vessels isn't completely developed so this can lead to problems with breathing cardiovascular wise premature babies are a great risk for PDA patent ductus arteriosus which we discussed during the normal newborn lecture remember the ductus arteriosus was there for fetal circulation and we should see this be closing however premature babies may have a patent ductus arteriosus leading to more blood flow through the lungs leading to respiratory distress syndrome another complication from it the premature baby could be thermoregulation issues or keeping warm we have a couple factors in play here for the preemie baby they have a great body surface area for not much mass so they have a great body surface area but they're pretty thin they have little subcutaneous fat if you recall that brown fatty layer was used for thermoregulation while the baby was learning how to eat while the mother's breast milk was coming in here the preemie has much less subcutaneous fat in addition they have thin skin so this can allow heat to leave the body and we also talked about the baby having a flexed position and how kind of curling up in that fetal position helps keep them warm and if you recall on doing the age assessment the gestational age assessment more immature babies have less flexion then a well-developed or full-term postdates baby would have so often we will hope these babies maintain thermal regulation you're having a neutral thermal environment will often put them in an isolate you can kind of see that here in this picture kind of looks like a clear plastic box for lack of a better word and we can provide them with heated air are in in this kind of environment to help keep them warm so they're not using all their energy just trying to maintain a neutral thermal environment and we certainly don't want them to become the cold stress which we'll be talking about premature babies also have gastrointestinal and genitourinary complications we know that their reflux is probably aren't going to be as well developed as a term baby therefore they can have problems sucking and swallowing and they have a poor gag reflex so they may Tucker easily if we're trying to orally feed them by breast or bottle they might not be able to suck and swallow all of the feeding that they need and they have a poor gag reflex so they're at risk for aspiration in addition they have a small stomach capacity and difficulty absorbing fat these are issues because they have an increased basal metabolic rate they have high calorie needs and a need for protein but a small stomach capacity and poor ability to suck and swallow so this isn't a great fit in addition they can have calcium and phosphorus deficiency typically these are deposited in the third trimester so if the baby is born prior to the third trimester or doesn't make it all the way through the third trimester they may have low calcium and phosphorus their risk for necrotizing enterocolitis you may hear the staff call this simply neck so if they have decreased peristalsis and potentially decrease blood flow to the intestine they're at risk for infection so they may get necrotizing enterocolitis and with this they can lose large portions of their intestine it can actually be life-threatening so this is problematic as far as genitourinary concerned they may have immature kidneys this can be a problem with formula much of this is processed through the kidneys and protein is processed through the kidneys so they have immature kidneys and a decreased glomerular filtration rate and this can impede their ability to process excess fluids they also have a limited ability to concentrate urine with all of this in mind as far as feedings are concerned we will often see them use keep en total parenteral nutrition initially or if they're able to use it or when they're able to use it will start gavage feedings or NG feedings and then slowly as the baby is able to tolerate it introduce oral feedings through bottle and breast once the baby is able to do all of the feedings orally we're very encouraged by that so you may see them in healthy situations starting to wean the baby to a crib so that it can maintain temperature on its own as long as its gaining weight and able to do all of its seedings by mouth you may also see them fortifying breast milk or using special formulas for these premature babies premature babies often have a paddock hematologic and immunological complications they're at risk for hypoglycemia what is hypoglycemia again it depends on the facility but typically this is a blood sugar of less than 40 or 45 milligrams per deciliter why are they at risk for hypoglycemia well it could be stressed or have cold stress and again preemies have poor stores they often have low iron stores iron is stored in the liver so that their liver is immature we expect that they'll have less iron store they're at greater risk for hyperbilirubinemia or jaundice why remember bilirubin is processed through the liver so if they have an immature liver there even a greater risk for hyperbilirubinemia they're less able to deal with the breakdown of red blood cells as far as the Amina logic system is concerned there greater risk for infection this is why it's even more important for mothers to breastfeed premature babies so that they get the antibodies that are in the breast milk so we certainly really want to encourage that within this population neurologically the baby's brain is developing very rapidly during the third trimester so if the baby is born prior to this this can be interrupted so we see a couple of things here that a baby is at risk for who's born prematurely their risk for interventricular or inter-cranial hemorrhage if you look here at the picture you can see where the ventricles are in the baby may have a bleed in some of these areas and we may not know the consequences of that for quite some times you think may see them do a head ultrasound to determine if there's an interventricular hemorrhage in addition it's the baby's neuro system that tells it to breathe so premature babies who don't have a fully developed neurological system may have episodes of apnea where they don't breathe or hold their breath for at least 20 seconds or have an incidence that's less than 20 seconds but there's color change associated with it like cyanosis will stimulate the baby or you may see them wait to see the baby will self stimulate or get itself out of the apnea episode apnea may also be related to a bradycardia you may hear them say the baby is having a Z and B's apneas and bradycardia so when they hold their breath or have that apnic episode the heart rate also begins to bottom out and the baby has a bradycardia associated with it parents often have questions about the long term complications associated with prematurity generally speaking the more mature a baby is the better its outcome will be as far as prematurity is concerned babies who are premature have much greater chance of sudden infant death syndrome in addition they have greater incidents of respiratory infections neurologic problems auditory problems problems hearing speech problems and retinopathy of prematurity retinopathy of prematurity has to do with the eyes or the retinas of the eyes this is often due to hyper oxygenation you'll see them generally start to wait until the pawl foxes you know in the low 90s before they will treat with oxygen because using too much oxygen is associated with potential problems and vision up to an including blindness now many of these long-term complications we may not see for a while even until the baby becomes a child and goes to school or starts to have developmental delays so this can be a big source of concern for parents and as providers it's difficult because many times babies are discharged and we don't know what their long-term life is going to be like however certainly premature babies are at greater risk for having these problems than term babies would be when caring for premature babies will expect to do cardiac and respiratory monitoring typically babies will have on EKG leads and respiratory monitors and also a pulse ox so we can see continually what their status is we would be monitoring cardiac function possibility of bradycardia which I mentioned respiratory wise possibility of tachypneic or APNIC episodes so we really want to keep a close eye on these so they will be on the monitor until discharge typically also we want to meet their growth and development needs here in this picture you can see the baby is kind of wrapped up and swaddled what we're trying to do is kind of recreate the uterus so keep the baby in a warm environment and that isolette if it needs oxygen therapy we would be doing that also you'll see positioning developmental positioning kind of putting the baby in that fetal position certainly we would not send the parents home with a positioner but while we have the baby on the monitors this is this is something safe that we can do because the baby is on the monitor so there's not a risk of it becoming entrapped or kind of tangled in that also underneath of this they'll kind of have them we call it lamb's wool but it is manufactured so it's you know safe and that kind of thing to help position the babies and to really comfort them often you'll see them kind of put a blanket over the isolette to kind of keep it warm and dark in the isolette like I said we just kind of want them to grow will provide nutrition as I mentioned many times they'll start with TPN or dextrose solution move to an NG feeding and then oral feedings as the baby can tolerate it typically these babies are fed every three hours on a feeding schedule so they'll start with one oral feeding is the baby tolerates it and then they'll work their way up to eight feedings so if the baby's eating every three hours there will be eight feedings within a 24-hour period there may be as I said calories added to breast milk if the mother is nursing and using a breast pump while the baby is learning how to eat effectively at the breast or they may use special formulas we're going to maintain fluid and electrolyte balance so sometimes these babies will be on an IV for that maintain thermoregulation this is often done in the isolette infection prevention is very very important as I said they have compromised immune systems they're at risk for necrotizing enterocolitis so we certainly want to make sure that we are using sterile technique for sterile procedures that we are hand-washing and also parents are asked to hand wash as well and we really want to promote bonding this is often an unexpected kind of occurrence for parents or it's not what they had in mind when they found out they were pregnant or picture themselves becoming parents so this can be a really scary time for them we want to encourage them to touch the baby if the baby is stable enough for them to do skin-to-skin even if the baby is getting an NG feeding if we can if the baby is stable enough have them hold the baby while the baby is getting ng feeding if the mother wishes to nurse put the baby to breast well it's getting the ng feeding so that it associates being at the breast with becoming full as much as we can do to promote bonding for both the baby and parents the better both of them will be post maturity refers to a situation where a baby is born after 42 completed weeks of gestation this means 43 weeks gestation or greater and this only applies to about 5% of deliveries complications from this include hypoglycemia or low blood sugar levels less than 45 because of depletion of stores also the potential for meconium aspiration related to asphyxia or lack of oxygen which stresses the baby out so it relaxes at anal sphincter has a bowel movement prior to delivery and breathe this in seizures related to a fixie up polycythemia or an increased number of immature red blood cells related to hypoxia the body tries to do this is compensatory measure congenital anomalies and we're really not sure why also cold stress related to poor development of the subcutaneous fat infants born to a substance-abusing mother are those who are born to a mother who's dependent on drugs and/or alcohol these can be illicit drugs or legal drugs they can be street drugs or they can be something prescribed and/or the use of alcohol complications can include congenital anomalies and/or developmental problem when a fetus is exposed to alcohol from the mothers consumption this can cause physical behavioral and cognitive problems this is called fetal alcohol syndrome there's a special appearance associated with fetal alcohol syndrome or FAS this is a flat nasal bridge a smooth frenulum the frenulum is the area of skin between the nose and the upper lip and a thin upper lip in addition they're often shortened stature they have microcephaly sucessfully is the head with micro small so often a small head and a thin appearance they can sometimes have long-term complications that can even reach into the school and adult years these include impulsive behavior they can have cognitive impairments speech and language problems in learning disabilities as we discuss drug abuse the mother may be using legal or illegal drugs so they could be street drugs such as cocaine or methamphetamine they can also be legal drugs perhaps she has a pain problem and she's addicted to pain medications risk to the fetus or newborn include asphyxia infection they could be small-for-gestational-age or large for gestational age often they can have low Apgar scores this could be associated with a need for resuscitation or she is addicted to morphine perhaps the baby is born with respiratory compromise they can have respiratory distress congenital anomalies behavioral problems and many times these babies can go through withdrawal and we'll start to see this at about 24-48 hours after delivery long-term problems associated with substance abuse of the mother during pregnancy include developmental problems cognitive problems social problems we can even see this very early with bonding inability to come social behavioral problems this can even include the ability to have feelings associated with anger happiness emotional issues GI problems and also respiratory problems how do we expect to care for the newborn of a substance abusing mother first of all if we know about this ahead of time we should promote prenatal care so that we're getting her the help she needs during the pregnancy in addition you'll often see an order for a newborn drug screen we can collect urine from a baby using what we call a you bag it's kind of a bag with a sticky substance around it you can either put over the penis if it's a boy or attempt to get it around the labia of a girl to collect a urine specimen with an order we would want to do this as soon as possible after delivery so that if the baby does have the drug in its system it's not cleared prior to us being able to get the specimen we would want to get social service involved so we can see is the mother going through treatment what are the plans for this baby does she have other children where are they is she caring for them appropriately can she care for this baby appropriately if it's not appropriate for her to maintain care for this baby where should the baby goat she have family involved all these questions social service can help us get answers to to provide a safe environment for the baby and one that's best for both the baby and the mother students often have questions about child abuse as it pertains to this if we have a positive drug screen on the baby it is considered child abuse otherwise its child endangerment does that mean that the baby will be taken away that's another common question that students have and patients have not necessarily social services and Children Services would look at the situation and determine where the baby is where it would best be placed if it should be with family issues if it should be in foster care if the mother's situation is appropriate for the baby to come home to it so that is not directly up to nursing although our input is valuable and it's very important that we document on bonding and on parent interactions with these children as well as all children we would expect medications to potentially be administered well if the mother is addicted to let's say morphine we would get an order for a very small amount of morphine and the baby would be weaned from that we don't want it to go through withdraw I can go through DTS just like an adult going through withdrawal can and that can be life-threatening so the baby is weaned in a couple of ways one of them is through the baby just gaining weight and growing so for example if I gave you Tylenol when you're an infant it would be effective however it probably wouldn't be effective for your adult weight so by giving the baby what it is addicted to you I use the example of morphine by the baby gaining and growing weight it kind of winds itself in addition to that we will do abstinence scoring so we will look at some things that will indicate how well the baby is doing or how it's not doing well and adjust the dose based on that and hopefully we will be able to wean down very slowly we'll want to reduce withdrawal symptoms these could include excessive sucking and then projectile vomiting diarrhea skin excoriation sweating inability to sleep for a period of time these are all signs that the baby is agitated also crying or a high-pitched cry difficulty consoling so we'll consider all these things in the abstinence scoring that we'll be doing these are all assigned a number and then we're given a number based on the total of all of those and the docs may use this as a decision factor when they're looking at the medication and the decision to wean down or does the baby need more is it not tolerating a wean sometimes it's you know one step back two steps forward so that it can take a very long time to get a baby off the medications small frequent feedings are often helpful like I said if the baby is sucking excessively and then it can projectile vomit sometimes some of this can be alleviated by doing small frequent feedings we want to monitor their GI status are they having diarrhea are they vomiting from all of this we'll also want to provide them with comfort as I said they can have a difficult time consoling themselves what can we do we can try to swaddle them can give them a pacifier for some non-nutritive sucking and try to calm them so in an upright position you might see staff kind of gently rocking a baby talking to the baby we want to provide skin protection especially since the baby is at risk for skin excoriation so this could include something like desitin to the bottom and also decrease stimulation so often these babies are put in a quiet area of the nursery one because they need the decreased stimulation if it's hard for them to rest and they're getting some sleep being and you know a noisy part of the nursery where other babies are crying or their bright lights or staff talking can really get these babies agitated in addition we want the other babies in the nursery to be able to you know grow and gain weight without being disturbed also these babies are in the hospital for a prolonged period of time it's important that we keep them on task developmentally so it's important that we talk to them or show them bright colors you might see them use a mobile within safe situation because developmentally we want to try to keep these babies on task so we may also see occupational therapy coming in to work with these babies so they're starting to be social so they can start to hold their neck up and meet all the developmental milestones they should be every baby has a metabolic screening done when the baby is greater than 24 hours of age this looks for potential inborn errors of metabolism there are quite a number of tests here that are tested for I'll go over some of the most common problems in order to complete this test the heel will be poked and blood is collected on a piece of filter paper as you can see in the picture there are some circles on the filter paper the circles are filled with blood that specimen is then sent to the state where it's processed and the results are sent to the pediatrician so in your clinical setting you probably will not see the results of these in the hospital video ketonuria PKU is a phenylalanine amino acid disorder where the body is unable to convert excess phenylalanine to tyrosine and this leads to cognitive problems galactosemia is a carbohydrate metabolism problem the metabolic screening also looks for homocysteine area congenital hypothyroidism sickle-cell anemia and cystic fibrosis just to name a few respiratory distress syndrome RDS is the most common respiratory problem of newborns this is mainly due to decreased levels of surfactant remember surfactant is the substance that allows for lung compliance and allows the alveolar sacs to open so what do you think the most common cause of RDS is its prematurity complications from RDS can include hypoxia because if there's distress in the respiratory system the respiratory system may not be able to adequately oxygenate this can then lead to respiratory acidosis and metabolic acidosis so we would see low pH levels the nursing assessment of respiratory distress syndrome surrounds the signs and symptoms of it so as far as a respiratory rate is concerned we will be assessing this what are we looking for we're looking for Tiffany oh so we're looking for the baby breathing quickly in addition we'll be assessing respiratory effort what do you think we'll see if the baby is in respiratory distress often we'll see grunting the baby is kind of singing with each breath as it exhales also nasal flaring a sign that the baby is really working hard to breathe so you'll see the the nostrils flaring to get as much air in as possible and also retractions this is where the baby is working so hard that you can actually see the intercostal spaces of the clavicles or ribs retracting is the baby breeze this they often say is GFR grunting flaring and retracting we'll also be monitoring a pulse ox will become concerned if it goes lower than the low 90s but typically will have a specific order notify position if respiratory rate is greater than 70 for example or pulse ox is less than 92 for example so we'll be monitoring these components will also be assessing color change an activity associated with these things if the baby is breathing quickly do you think it will be able to eat well probably not if it has a low pulse ox what do you think its color might be pale or cyanotic perhaps so we'll be monitoring those things as well kind of getting a full picture how is respiratory distress syndrome managed well hopefully we can prevent it by preventing a preterm birth so we know that the woman is in preterm labor you may see medications such as magnesium sulfate being used in addition we'll expect to monitor Celeste stone do you remember what Celeste stone is that is the steroid that we give intramuscularly to the mother we will expect to administer two doses and this is to help mature the baby's lungs after delivery we can administer surfactant this would be done through an endotracheal tube so they Lin to intubate the baby and then administer it that way the baby may need respiratory support this could include a ventilator CPAP or o2 administration so it would depend on the severity of the respiratory distress syndrome for what kind of respiratory support the baby would need oftentimes this decision is made by the respiratory therapist in the physician along with nursing input of what our assessment is another problem associated with the respiratory system is transient Kipp Nia of a newborn keiki n this often affects term large for gestational age or late preterm babies babies that are close to being term but not quite there so it's a little bit different than respiratory distress syndrome because it affects mainly term babies risk factors for TPN include maternal diabetes macrosomia so a large baby a c-section delivery why do you think a c-section delivered baby would be a higher risk for a respiratory issue do you remember they don't have that recoil the vaginal delivery where the baby is kind of squished as it's being delivered for lack of a better term and then that causes that the recoil causes the baby to breathe so it doesn't have that mechanism to clear the fluid so there's increased lung fluid there male babies are more at risk for having T quien and then if there was fetal hypoxia we're the signs and symptoms of transient to keep me as a newborn they really do resemble that a respiratory distress syndrome you may see grunting flaring retracting as I discussed you may see a color change or cyanosis if the pulse ox is low they may be breathing quickly they may have to keep me up you may see mild respiratory and/or metabolic acidosis so mildly a low pH however here's where there's a big difference in addition to the gestational age is that the symptoms usually resolve within 24 hours not always but generally we'll see this resolved hence the name transient transient to kidney of a newborn so it's transient it will pass to keep me up there breathing fast of the newborn so the name really gives away the clinical picture transient tachypnea of the newborn another respiratory problem meconium aspiration syndrome we've also mentioned this during the high-risk lecture what happens here as a review well the fetus relaxes its anal sphincter because it's stressed lack of oxygen causes it to do this and this results in having a meconium stool in the amniotic fluid prior to delivery and this can be aspirated during the baby's first breath so what kind of risk does this pose what can cause obstruction of the airway and can cause pneumonia it can even inactivate surfactant and it can cause pulmonary hypertension so how is this managed if it's light meconium there's just a little bit you may see a not much management at all not much concern however if there is thick meconium or they'll call this pea soup you can really see a lot of it kind of chunky in the amniotic fluid this baby would not be dried and stimulated after delivery it would not be stimulated to cry instead it would be taken immediately over to the warmer where it would be suction and you can see that in this picture here so there's a meconium a special suction for this so that they would go down as though they're intubating the baby and suction out the airway to prevent these risks from occurring cold stress is excessive heat loss resulting in compensatory mechanisms to maintain adequate body temperature what are the compensatory mechanisms well they can breathe quickly so we might see increased respirations they're trying to work hard to maintain their temperature and they may have non shivering thermogenesis what does this mean this means gaining temperature or thermogenesis they're using the brown fatty layer as a review how does heat loss occur do you remember a few of the factors conduction convection those were a couple of them evaporation is a big one right after delivery because the baby is wet so we dry and stimulate we're encouraging the baby to breathe and we're drying the baby to prevent evaporation who do you think is a greatest risk for cold stress a baby who is large for just a tional age a baby who is average for gestational age or one who is small for gestational age who has the least amount of brown fat for maintaining body temperature and inability to remain in a flexed position oftentimes those are preemies small-for-gestational-age babies our greatest risk for cold stress cold stress is very concerning because it can result in other problems decreased surfactant productions this would lead to respiratory problems it can lead to metabolic acidosis hypoglycemia and hyperbilirubinemia so let's look here at this chart to explain how each of these occurs we will move left to right so looking at cold stress this can cause the release of norepinephrine in order to stimulate Brown fat metabolism to keep the baby warm in doing this there's pulmonary vasoconstriction which results in decreased blood flow through the lungs so there's decreased blood flow through the lungs there's going to be hypoxemia which results in acidemia and that again plays into this through increasing the pulmonary vasoconstriction cold stress also results in decreased surfactant production so this results in add elective and decreased oxygenation which leads to hypoxemia cold stress can lead to increased anaerobic metabolism which leads to increased fatty acids therefore hyperbilirubinemia so babies under cold stress can then become jaundiced cold stress can lead to an increased metabolic rate as the baby is trying to keep warm which means the baby meat needs more oxygen this means that the baby needs more glucose and that leads to hypoglycemia or a blood sugar of less than 40 or 45 so just being cold can make the baby have breathing problems have low oxygen levels be in metabolic acidosis low blood sugar levels and even become jaundice and this visual does a really nice job showing how each of these things results from cold stress so it's very important particularly in these preemies and in these babies who are small for gestational age or greater risk for cold stress that we keep them warm that's why a neutral thermal environment is so important for these kiddos jaundice can place a baby at risk now as a review we've talked about this during the normal newborn lecture and also during the high-risk pregnancy lecture so this much of this will be a review for you physiologic jaundice occurring after 24 hours of life can be normal however it is very concerning when jaundice is present within the first 24 hours this may lead to kernicterus which is the unconjugated bilirubin settling in the brain this can lead to permanent and irreversible brain damage this can also lead to hydrops fetalis this is anemia severe edema and organ shutdown associated with maternal antibody attachment so as a review when is this most frequently seen these are most frequently seen with a low immunization that would be when there's rh sensitivity is an Rh negative mother at risk for this or Rh positive mother at risk for this it's an Rh negative mother who is pregnant with an Rh positive fetus who has already formed antibodies against Rh positive blood that is who is at risk for this also we talked about ABO sensitivity so if a woman is Type O and the baby is a B or a B and she's exposed to that she can have a reaction as well so again most concerning when jaundice is present during the first 24 hours that means that that bilirubin level is really pretty high so we'll be expecting to draw a Coombs and indirect coombs from the mother and the baby for further information feel free to review the normal newborn and high-risk pregnancy I did want to review this however I don't want to be too redundant but jaundice does place a baby at high risk in some of the high risk of diagnosis that we've talked about already lead to jaundice management for jaundice might include photo therapy as we've talked about the billy lights the Billy blanket the light can help the breakdown is the Billy Reuben so the baby can excrete it we talked about maximum skin exposure being important we talked about protecting the baby's eyes during this also in very severe cases where we're thinking that there may be rh sensitivity involved or ABO incompatibility there may be an exchange transfusion as you can see here in this picture what's happening is the baby's blood is removed and donor blood is replaced so the concern here could be you know HIV or tainted donor blood testing is very good for this now nowadays but this may be of concern for parents and it is a valid one however like I said testing is done on the blood this would come from the blood bank this concludes the high risk newborn lecture if you have any questions I'd like to hear from you thank you

2 Replies to “High Risk Newborn”

  1. Dr. Please suggest me I M BLOOD GRUP 0+ and my baby boy born B+ 34week delivery
    Resperiatory Pneumonia doctors suggested me 14days Antibiotics course let me know he is on high risk or not now one week completed his birth wait 2.400 and now he is lose 2.360 his eyes is looking yellowish for 3/4 he was under phototherapy also having G6pd deficiency 02 half liter fluctuations 30/61/
    Please suggest me what type of questions I Ask from Doctor

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