CONCEPT, ASSESSMENT, GOALS, OBJECTIVES OF

HIGH RISK NEWBORN

INTRODUCTION

A newborn should have a thorough evaluation performed within 24 hours of birth to

identify any abnormality that would alter the normal newborn course or identify a medical
condition that should be addressed (e.g., anomalies, birth injuries, jaundice, or cardiopulmonary
disorders) . This assessment includes review of the maternal, family, and prenatal history and a
complete examination. Depending upon the length of stay, another examination should be
performed within 24 hours before discharge from the hospital.

The high-risk period begins at the time of viability (the gestational age at which survival
outside the uterus is believed to be possible, or as early as 23 weeks of gestation) up to 28 days
after birth and includes threats to Life and health that occur during The prenatal, perinatal, and
postnatal periods.

CONCEPT OF HIGH RISK NEWBORN

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MEANING OF NEONATE

From birth to under four weeks of age (<28 days), the infant is called neonate or newborn.
First week of life (<7 days or <168 hours is known as early neonatal period. Late neonatal period
extends from 7th to < 28th day.

DEFINITION OF HIGH RISK NEWBORN

A newborn regardless of gestational age or birth weight, who has a greater –than average
chance of morbidity or mortality because of conditions or circumstances superimposed on the
normal course of events associated with birth and the adjustment to extrauterine existence.

Encompasses human growth and development from the time of viability ±28 days
following birth and includes threat to life and health that occur during the prenatal, perinatal, and
postnatal periods.

CLASIFICATION OG HIGH RISK NEWBORN

High-risk infants are most often classified according to birth weight, gestational age, and
predominant pathophysiologic problems. The more common problems related to physiologic

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status are closely associated with the infant’s state of maturity and usually involve chemical
disturbances (e.g., hypoglycemia, hypocalcemia) and consequences of immature organs and
systems (e.g., hyperbilirubinemia, respiratory distress, hypothermia).

CLASSIFICATION ACCORDING TO SIZE

Low-Birth-Weight (LBW) Infant—An infant whose birth weight is less than 2500 g (5.5
lb), regardless of gestational age
Very Low–Birth-Weight (VLBW) Infant—An infant whose birth weight is less than
1500 g (3.3lb)
Extremely Low–Birth-Weight (ELBW) Infant—An infant whose birth weight is less
than 1000 g (2.2 lb)
Appropriate-For-Gestational-Age (AGA) Infant—An infant whose weight falls between
the 10th and 90th percentiles on intrauterine growth curves.
Small-For-Date (SFD) Or Small-For-Gestational-Age (SGA) Infant—An infant whose
rate of intrauterine growth was slowed and whose birth weight falls below the 10th
percentile on intrauterine growth curves.
Intrauterine Growth Restriction (IUGR)—Found in infants whose intrauterine growth is
retarded (sometimes used as a more descriptive term for the SGA infant)
Large-For-Gestational-Age (LGA) Infant—An infant whose birth weight falls above the
90th percentile on intrauterine growth charts

CLASSIFICATION ACCORDING TO GESTATIONAL AGE

Preterm (premature) infant—An infant born before completion of 37 weeks of gestation,
regardless of birth weight
Full-Term Infant—An infant born between the beginning of 38 weeks and the
completion of 42 weeks of gestation, regardless of birth weight
Posterm (Postmature) Infant—An infant born after 42 weeks of gestational age,
regardless of birth weight
Late-Preterm Infant—An infant born between 34 and 36 weeks of gestation, regardless
of birth weight

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CLASSIFICATION ACCORDING TO MORTALITY
Live Birth—Birth in which the neonate manifests any heartbeat, breathes, or displays
voluntary movement, regardless of gestational age
Fetal Death—Death of the fetus after 20 weeks of gestation and before delivery, with
absence of any signs of life after birth
Neonatal Death—Death that occurs in the first 27 days of life; early neonatal death
occurs in the first week of life; late neonatal death occurs at 7 to 27 days
Perinatal Mortality—Describes the total number of fetal and early neonatal deaths per
1000 live births
Postnatal Death—Death that occurs at 28 days to 1 year after birth

CLASSIFICATION ACCORDING TO BIRTH WEIGHT

Low Birth Weight - Birth weight less than 2500g regardless of gestational age
Moderately Low Birth Weight - birth weight is between 1501g to 2500g.
Very Low Birth Weight -birth weight is less than 1500g.
Extremely Low Birth Weight - birth weight less than 1000g.

CLASSIFICATION ACCORDING TO SIZE

Appropriate for Gestational Age (AGA) - birth weight falls between the 10 and 90
percentile
Small for Gestational Age ( SGA) - birth weight falls below the 10 percentile
Large for Gestational Age (LGA)- birth weight falls above the 90 percentile

MEDICALLY HIGH RISK NEWBORN (MHRN) ELIGIBILITY CRITERIA

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PREMATURITY (less than 32 weeks gestation)
VERY LOW BIRTH WEIGHT (less than 1500 grams)
SIGNIFICANTLY SGA (small for gestational age) failure to thrive, IUGR (intrauterine
growth retardation) less than 5th percentile.
PROLONGED hypoxemia, academia, repetitive apnea, required assisted ventilation .40
hours.
METABOLIC PROBLEMS, i.e hypoglycemia, hypocalcemia
HYPERBILIRUBINEMIA (considered when persistent and untreated
hyperbilirubinemia requires exchange transfusions and/or is associated with congenital
anomalies).
NEONATAL SEIZURES or seizures beyond the neonatal period.
SERIOUS BIOMEDICAL FACTORS i.e. CNS bleeds, RDS (respiratory distress
syndrome) confirmed infection, chronic lung disease.
MULTIPLE CONGENITAL ANOMALIES requiring special services, but with
presumed potential for normal developmental outcome.
HISTORY OF MATERNAL CHEMICAL EXPOSURE and/or substance abuse i.e.
alcohol hydantoin, warfarin and cocaine.
PERSISTENT FEEDING PROBLEMS
PERSISTENT TONAL PROBLEMS
CONTINUED evidence of delay in one or more developmental areas and poor parent-
infant attachment.

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IDENTIFICATION OF HIGH RISK NEWBORNS
Maternal diabetes
Maternal narcotics during labor
Maternal substance abuse
Fetal asphyxia
Difficult/prolonged labor causing birth trauma
Multiple gestation
Preterm or postterm delivery
Congenital anomalies
Maternal or neonatal infection
SGA or LGA
Apgar score < 6 at 1 min or < 7 at 5 min

PRETERM INFANTS

MEANING - An infant born before term (<=36 weeks); A low birth weight infant: </=1300-
2000g (Philippine Standards) (,2.5kg)

A newborn born before complete maturity; born before body and organ system have
completely matured is called prematurity.

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INCIDENCE:

Highest among low socio economic class

Largest - of admission to NICU
12% of all pregnancies

CAUSES

Unknown
Maternal Factor
§ Malnutrition
§ Preeclampsia (toxemia of pregnancy)
§ Chronic Medial illness (Cardiac/kidney disease/DM)
§ Infection (UTI, vaginal infection)
§ Drug Use (coccaine, tobacco, alcohol)
§ Abnormal structure of the uterus
§ Previous Preterm Births
Pregnancy Related Causes
§ Hypertension
§ Incompetent Cervix
§ Placental Previa/ Abruptio Placenta
§ PPROM, poly/oligohydramnios
Fetus
§ Chromosomal abnormalities

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 § Intrauterine Infection
§ Anatomic Abnormalities
§ IUGR
§ Multiple gestations

DIAGNOSTIC EVALUATION

Appraisal is made as soon as possible after admission to the nursery.

HEAD

Head circumference is large in comparison with chest (reflects cephalocaudal direction of

growth)
The fontanels are small and bones are soft - Soft cranium subject to characteristic non-
intentional deformation.
Bones of skull and ribs - soft Very small and appear scrawny,

EYES

Absent eyebrows
Eyes closed

EARS

Ears are poorly supported by cartilage (soft and pliable)

SKIN

Bright pink (often translucent) with small blood vessels

Smooth and shiny (may be edematous) with small blood vessels clearly visible
underneath thin epidermis
Fine lanugo hair abundant over body, sparse, fine & fuzzy on head
Less subcutaneous fat (skin is wrinkled)

SOLES AND PALMS

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 Minimal creases

HARLEQUIN COLOR

Skin color changes when preterm infant is moved;

Upper half or one side of the body is pale or one side of the body is red.

CHEST

Small breast bud size with underdeveloped nipples

GENITALIA

Male Infants - few scrotal rugae, undescended testes

Female infants- Labia and clitoris are prominent in females

POSTURE

Complete relaxation with marked flexion and abduction complete relaxation with marked
flexion and abduction of the thighs;
Random movements are common with slightest stimulus

ACTIVITY

Inactive and listless

EXTREMITIES

Extremities maintain an attitude of extension and remain in any position in which they
are placed.

REFLEXES

partially developed
Sucking absent, weak or ineffectual; swallow, gag, cough reflexes - ABSENT

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TEMPERATURE INSTABILITY

Heat regulation poorly developed in the preterm infant because of poor development of
CNS

IMMUNITY

Increased susceptibility to infection

RESPIRATION

Respirations are not efficient because of muscular weakness of lungs and rib cage and
limited surfactant production;
Retraction at xiphoid is evidence of air hunger
Infants should be stimulated if apnea occurs
HMD/RDS, chronic lung disease, BPD, apnea of prematurity

CIRCULATION

Greater tendency toward capillary fragility in the preterm infant

Red and white blood cell counts are low with resulting anemia during first few months of
life.

NEUROMUSCULAR

Neuro - Higher incidence of intracranial hemorrhage in the preterm infant

Muscle twitching, convulsions, cyanosis, abnormal respirations, and a short shrill cry
Cerebral palsy, visual -motor deficits, altered intellectual functions

GASTROINTESTINAL TRACT

Nutrition is difficult to maintain because of weak sucking and swallowing reflexes, small
capacity of stomach, and slow emptying time of the stomach

RENAL

Reduced glomerular filtration rate results in decreased ability to concentrate urine and
conserve fluid.

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 Higher ECF, vulnerable to fluid and electrolyte imbalance

PREVENTION

Prenatal Care

Good nutrition and education

Identification of mothers at risk
Educate on symptoms of PT labor
Avoid heavy/repetitive work or standing long periods of time

TREATMENT

Oxygen, IVF
Umbilical catheterization
Intravenous Fluid
Medications
Blood Intravenous Fluid extraction
X-ray
Special feedings of breast milk/formula
Kangaroo care

NURSING CARE

Maintain airway
Check respirator function if employed
Position to promote ventilation
Suction when necessary
Maintain temperature of environment
Administer oxygen only if necessary
Observe for changes in respirations, color, and vital signs
Check efficacy of Isolette
Maintain heat, humidity, and oxygen concentration; monitor oxygen carefully to prevent
retrolental fibroplasias
Maintain aseptic technique to prevent infection

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 Monitor for hypoglycemia ,hyperbilirubinemia & hemorrhage
Careful skin care & positioning to prevent breakdown
Adhere to the techniques of gavages feeding for safety of the infant
Observe weight -gain patterns
Determine blood gases frequently to prevent acidosis
Institute phototherapies by letting them verbalize and ask questions to relieve anxiety
Provide flexible and liberal visiting hours for parents as soon as possible
Allow parents to do as much as possible for the infant after appropriate teaching
Arrange follow-up before and after discharge .

POSTMATURE INFANTS

MEANING

Baby born after 42 weeks AOG/ 294 days past 1 st day of mother’s LMP; regardless of
birth weight is referred to as postmature infants.

OTHER NAMES- Post term, post maturity, prolonged pregnancy, post datism

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INCIDENCE

7% (3.5 -15%) of all pregn ancies

CAUSES

Unknown
History of >/= 1 previous post term pregnancies
Miscalculated due date (not sure of LMP)
Fetal Risk
§ Progressive placental dysfunction ±placenta (supplies nutrient & oxygen) ages toward the
end of pregnancy ---may not function efficiently
§ Amniotic fluid volume decreases, fetus may stop gaining weight/ weight loss
§ Decreased amniotic fluid may lead to cord compression during labor
§ Increased risk of MAS and hypoglycemia
§ Increasing size (mainly length) & hardening of skull may contribute to CPD
§ GRE ATEST RISK: during stresses of labor & delivery especially in infants of
primigravidas.

CHARACTERISTICS OF INFANTS

 Absent lanugo,
 Little if any vernix caseosa,
 Abundant scalp hair,
 Overgrown nails

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  Dry, peeling skin (cracked, parchmentlike & desquamating)
 Wasted physical appearance (reflects intrauterine deprivation)
 Minimal fat deposit (depleted subcutaneous fat) thin, elongated appearance
 Meconium staining - seen in skin folds w/ vernix caseosa
 Visible creases palms/ soles

DIAGNOSIS:

Physical Examination
Ultrasound Scanning
Non -stress testing
Estimate amniotic fluid volume

MANAGEMENT

Check respiratory problems related to meconium

Suctioning
Blood test for hypoglycemia

PREVENTION

Accurate due date and Ultrasound Scanning

Cesarean section/ induction of labor -recommended.

HIGH RISK RELATED TO PHYSIOLOGIC FACTORS

HYPERBILIRUBINEMIA

MEANING- Hyperbilirubinemia refers to excessive level of accumulated Bilirubin in the blood

JAUNDICE or ICTERUS- yellowish discoloration of skin, sclera, nails. Relatively benign but
it can also be pathologic

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PATHOPHYSIOLOGY

RBC Destruction

Globin Heme

Protein (used by the body) Unconjugated Bilirubin

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 Liver

Bilirubin detached from albumin through enzyme glucoronyl transferase or glucoronic acid

Conjugated Bilirubin

Excreted into Bile (feces and urine)

Hyperbilirubinemia - Result from increased unconjugated/ conjugated bilirubin

Bilirubin - one of the breakdown products of one of the breakdown products of hgb from RBC
destruction

Unconjugated Bilirubin - insoluble, bound to insoluble, bound to albumin

Intestines (or) bacterial action - reduces conjugated bilirubin

Urobilinogen - pigment that gives stool its characteristic odor.

COMPARISION OF MAJOR TYPES OF UNCONJUGATED HYPERBILIRUBINEMIA

PHYSIOLOGIC BREAST- BREAST MILK HEMOLYTIC

JAUNDICE FEEDING JAUNDICE (LATE DISEASE
ASSOCIATED ONSET)
JAUNDICE
(EARLY ONSET)
CAUSE
Immature hepatic Decreased milk Possible factors is Blood antigen
functionor increased intake related to breast milk that incompatibility

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bilirubin load from fewer calories prevent bilirubin causes hemolysis of
RBC hemolysis consumed by infant conjugation less large # of RBCs.
before mother’s milk frequent stooling Liver unable to
is well established conjugate and excrete
enterohepatic excess bilirubin form
shunting hemolysis.

ONSET
After 24 hours 2nd- 4th day 5th – 7th day During 1st 24 hrs
(preterm infants, (levels increase faster
prolonged) than 5mg/day)
PEAK
75- 90 hours 3rd – 5th day 10th – 15th day Variable
DURATION
Declines on 5th – 7th Variable May remain Dependent on
day jaundiced x 3-12 severity and
weeks or more treatment

THERAPY
Increase frequency of Frequent (10 – Increase frequency of Monitor TcB/TSB
feedings and avoid 12x/day) breast breast feeding; use no level. Perform risk
supplements. feeding, avoid supplementations assessment
Evaluate stooling glucose water, water (glucose water): POSTNATAL-
pattern. Monitor supplements or cessation of phototherapy;
transcutaneous formula. Evaluate breastfeeding not administer IVIG per
bilirubin (TcB)/ Total stooling pattern; recommended. protocol; if severe,
Serum Bilirubin stimulate as needed. Perform risk perform exchange
(TSB) assessment. transfusion.
THERAPY :
Perform risk Use phototherapy if Consider performing PRENATAL –
assessment. Use bilirubin level additional transfusion (fetus)
phototherapy if increases evaluations: G6PD, prevent sensitization

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bilirubin level significantly (17-22 direct and indirect (Rh incompatibility)
increases mg/dl) or significant serum bilirubin, of Rh- negative
significantly hemolysis is present. family history and mother with Rhig
(>5mg/dl/day) or others as necessary. (Rhogam)
significant hemolysis
is present

BREAST – FEEDING . BREAST MILK HEMOLYTIC DISEASE

ASSOCIATED JAUNDICE JAUNDICE (LATE
(EARLY ONSET) ONSET)
THERAPY:
If phototherapy is instituted, May include home PRENATAL – if mother Is
evaluate benefits and harm of phototherapy with a breastfeeding, assist with
temporarily discontinuing temporary (10-12hr) maintenance and storage of
breastfeeding; additional discontinuation of a milk; may bottle-feed
assessments may be required. breastfeeding, a subsequent expressed milk as appropriate
Assist mother with TSB may be drawn to to therapy. Minimize
maintaining milk supply, feed evaluate a drop in serum maternal- infant separation
expressed milk as levels. and encourage contact as
appropriate. After discharge, Assist mother with appropriate.
follow up according to hour maintenance of milk supply
of discharge. and reassurance regarding her
milk supply and therapy.
Use formula supplements
only at practitioner’s
discretion.

CAUSES

Physiologic (developmental) factors (prematurity):

Excess production of bilirubin - Hemolytic disease, biochemical defects, bruises

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 Hemolytic disease - blood antigen incompatibility blood antigen incompatibility,
hemolysis of RBC; liver unable to conjugate & excrete excess bilirubin from hemolysis

PHASES OF PHYSIOLOGIC JAUNDICE

2 PHASES: TERM INFANTS

1ST phase - Bilirubin: 6mg/dl on 3rd day

Date Of Labour : decreased to 2--3mg/dl by 5th day

2nd phase - Steady plateau without increase/decrease level

12th -14th day: levels decreased to normal (1mg/dl)

Pattern varies according to racial group, method of feeding, gestational age

PRETERM: Bilirubin - 10-12mg/dl at 4-5days slowly decrease by 2-4 weeks.

CLINICAL MANIFESTATIONS

Jaundice most obvious sign

Yellowish discoloration: sclera, nails, skin
If it appears within 1st 24 hours: hemolytic disease of Newborn, sepsis, maternally-
derived diseases (DM, infections)
Appears on 2nd or 3rd day, peaks on 3rd ±4th day, declines on 5th ±7th day: physiologic
jaundice (varies according to ethnicity)
Intensity of jaundice is not always related to the degree of hyperbilirubinemia

BREASTFEEDING JAUNDICE (Early onset)

Early onset Begins at 2--4days of age; 12-13% of Breastfeeding infants

Related to process of breastfeeding, results from decreased caloric & fluid intake by
Breastfeeding infants before milk supply is well-established (fasting is associated with
decrease established (fasting is associated with decreasehepatic clearance of bilirubin)

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 Feeding (or) peristalsis more rapid passage of meconium more rapid passage of
meconium decreased amount of reabsorption of unconjugated bilirubin
Feeding introduces bacteria to aid in reduction of bilirubin to urobilinogen
Colostrums, natural cathartic, facilitates meconium evacuation

BREAST MILK JAUNDICE (late onset)

Late onset : 4th -7th day of age; 12-13% of Breastfeeding infants

Rising levels peak at 2nd week gradually diminish. May remain jaundiced x 3-12 weeks or
more 12 weeks or more infants are well
May be caused by factors in Breast Milk (pregnanediol, fatty acids, B- glucorinidase) that
either inhibit conjugation or decrease excretion of bilirubin
Less frequent stooling by Breastfeeding infants may allow for extended time for
reabsorption of bilirubin from stools
Excess production of bilirubin - Hemolytic disease, biochemical defects, bruises

DIAGNOSITC EVALUATION

Serum Bilirubin (B1: 0.2-1.4mg/dl)

Jaundice appears at >5mg/dl
Evaluation based on:
§ Timing of appearance of clinical jaundice
§ Gestational age at birth
§ Age in days since birth
§ Family history including maternal Rh factor
§ Evidence of hemolysis
§ Infant¶s physiologic status
§ Progression of serum bilirubin levels
Persistent jaundice over 2 weeks in full-term, formula fed term, formula fed infant
Total serum bilirubin levels 12.9mg/dl (term infant) or over 15mg/dl (preterm); upper
limit for breastfeeding infant ± 15mg/dl
Increase serum bilirubin >5mg/dl/day
Direct bilirubin (B2) 1.5 -2mg/dl

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 Total serum Bilirubin ±over 95th percentile for age (in hours)on hour--specific risk
nomogram
Transcutaneous Bilirubinometry , noninvasive monitoring of bilirubin via cutaneous
reflectance mechanisms; allow for repetitive estimations of bilirubin
Hour –specific Serum Bilirubin Levels ±predict newborn at risk for rapidly rising levels
Recommended by AAP for monitoring healthy Newborn >35wks AOG before discharge
from hospital
Carbon monoxide indices in exhaled breath ± CO is produced when RBC is broken down

TREATMENT:

Postnatal

 Phototherapy - main form

 Exchange transfusion - reduce high bilirubin levels that occur with hemolytic disease

Prenatal

 Transfusion (fetus)
 Phenobarbital ±hemolytic disease; effective when given to mother several days before
delivery

COMPLICATIONS

Bilirubin Encephalopathy/ Kernicterus- unconjugated bilirubin highly toxic to the

neurons
o Syndrome of severe brain damage due to deposition of unconjugated bilirubin in
brain cells (extremely high B1 level increase crosses the blood -brain barrier)
Kernicterus- yellow staining of brain cells that may result in bilirubin encephalopathy
brain injury
Metabolic acidosis
Low serum albumin level
Intracranial infections (meningitis)
Abrupt increase in BP

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 Conditions that increase metabolic demands for oxygen and glucose - fetal distress,
hypoxia, hypothermia, hypoglycemia

PROBLEMS RELATED TO BIRTH TRAUMA

FACIAL PARALYSIS
From pressure on facial nerve during delivery
Affected side unresponsive when crying
Resolves in hours/days

ERB’S PALSY (ERB- DUCHENNE PARALYSIS)

Associated with stretching or pulling head away from shoulder during delivery
Signs: Flaccid arm, elbow extended, hand rotated inward, Moro & grasp reflexes absent
on affected side
Requires immobilization & reposition for 2 to 3 hrs

FRACTURED CLAVICLE
Bone most frequently fractured during delivery
Associated with CPD
Signs: limited ROM (range of motion), crepitus, absent Moro reflex on affected side
Heals quickly, handle gently, immobilize arm

ASPHYXIA
Inadequate tissue perfusion
Signs: acidotic scalp or cord pH
Low Apgar score (< 4 at 1 min)
Begin resuscitation immediately

NEONATAL RESPIRATORY DISTRESS

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 Common causes
o Preterm infants (Primarily associated with infants < 37 wks)
o Meconium aspiration syndrome (MAS):
o Transient tachypnea of the newborn (TTN): delayed fluid absorption in lungs.
Signs
o Tachypnea
o Intercostal retractions
o Nasal flaring
o Expiratory grunting, diminished breath sounds
o PaO2 <50, PCO2 >60
o Central cyanosis (late finding)
Interventions
o Radiant warmer or isolette to maintain neutral thermal environment & prevent
cold stress; oxygen demands increase if neonate is cold.
o Warmed, humidified oxygen
o Withhold feedings if RR > 60 breaths/min
o Position side lying or supine with neck slightly extended
o Suction the baby to maintain a patent airway
o Monitor oxygen saturation and/or ABGs as ordered

MECONIUM ASPIRATION SYNDROME (MAS)

Prenatal asphyxia causes relaxation of anal sphincter & passage of meconium into amniotic fluid

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 Fetus/infant inhales meconium into airway

Forms mechanical obstruction; air can be inhaled but can’t be exhaled

Lungs become hyper inflated

Irritating to airway

Causing chemical pneumonitis

Signs:
o Fetal distress
o Apgar score < 6 at 1 & 5 min,
o Distended
o Barrel-shaped chest,
o Diminished breath sounds,
o Yellow staining of skin, nails & cord

Interventions
o Suction oropharynx & nasopharynx after head is born & shoulders and chest still
in birth canal
o Endotracheal suctioning indicated before stimulating respirations unless infant
crying & vigorous
o Administer O2 and anticipate need for ventilation
o Perform chest physiotherapy routinely

TRANSIENT TACHYPNEA OF THE NEWBORN (TTN)

Failure to clear airway of excess fluid at delivery

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 Primarily term infants, especially if C/S (miss mechanical squeeze of vaginal delivery)
Signs:
o Grunting
o Flaring
o Mild cyanosis
o Tachypnea, - respirations can be as high as 100 to 140 breaths/min
Nursing Management
o O2 as needed to maintain PO2
o Usually resolves within 72 hours

COLD STRESS
All newborns at risk for hypothermia
Keep temp 97.6-99.2 by
Neutral thermal environment
o Delay bath until temperature stable
o Dry iimmediately after bath
o Under warmer or skin to skin after delivery
o Wrap with warm blankets
o Check O2 sat and blood glucose
o Chronic hypothermia can be early sign of sepsis

HYPOGLYCEMIA
Blood glucose < 40 mg/dl in term newborn
At risk
o IDM (Infant of a Diabetes Mellitus)
o SGA (Small for Gestational Age)
o Premature
o Infants with cold stress
o Hypothermia

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 o Delayed feedings
Signs:
o Tremors
o Jitteriness
o Lethargy
o Decreased muscle tone
o Apnea
o Anorexia
Nursing Management
o Check blood glucose of at-risk infants,(30 min if IDM) & on any symptomatic
newborn.
o Feed (breast or bottle)
o Reassess glucose before next feeding

INFANT OF A DIABETIC MOTHER (IDM)

Maternal glucose crosses placenta

Fetal pancreas secretes more insulin to metabolize glucose

Increased insulin decreases surfactant production.

Signs
o LGA (Large for Gestational Age)
o Hypoglycemia
o RDS (Respiratory Distress Syndrome)
o False positive L/S ratio,
o Increased risk for congenital anomalies (especially cardiac and spinal)

Nursing Management

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 o Assess for birth trauma
o Monitor Blood glucose at 30 min and 1, 2, 4, 6, 9 12 and 24 hours
o Treat hypoglycemia

NEWBORN SEPSIS
Group B streptococcus most common cause
Complicated by immature immune system & lack of IgM
Associated with PROM
Prolonged labor
Maternal infection.

Signs:
o Lethargy
o Seizure activity
o Pallor
o Hypothermia
o Poor feeding
o Respiratory distress
o Apnea
o Tachycardia
o Bradycardia
o Hyperbilirubinemia

Nursing Management:
o Obtain cultures (blood, urine, CSF)
o Start antibiotics star. After 72 hrs,
o Treatment stopped if culture negative & asymptomatic.
o Continue antibiotics for 1014days if culture reports positive

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FETAL ALCOHOL SYNDROME (FAS)
Alcohol crosses placenta

Interferes with protein synthesis

Increasing risk of congenital anomalies,

Mental deficiency & IUGR

Signs
o SGA
o Small eyes
o Flat midface
o Long, thin upper lip
o Flat upper lip groove
o Irritable
o Hyperactive
o High pitched cry

Nursing Management
o Reduce environmental stimuli
o Swaddle to increase feelings of security
o Sedatives for withdrawal side effects

NEONATAL ABSTINENCE SYNDROME (NAS)

Etiology
o Repeated intrauterine drugs exposure causes fetal drug dependency, degree of
withdrawal depends on type & duration of addiction

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 Signs
o Hyperactivity, jitteriness & shrill, persistent cry
o Frequent yawning & sneezing, nasal stuffiness
o Sweating
o Absence of “step” & “head-righting” reflex
o Developmental delays
o Feeding difficulties (vomiting, regurgitation, diarrhea) increased need for non-
nutritive sucking

Nursing Management
o Position infant on side to facilitate drainage of mucus
o Suction PRN to maintain patent airway
o Decrease environmental stimuli, swaddle for comfort
o Intake & output, daily weight
o Obtain meconium and/or urine for drug screening
o Meds may include paregoric elixir, thorazine &Valium, methadone, phenobarbital
o Pacifier for non-nutritive sucking
o Don’t give Narcan to infant born to narcotic addict

INTENSIVE CARE FACILITIES FOR HIGH RISK NEWBORN

Rapid advances in our understanding of the pathophysiology of the neonate and increased
capacity to apply this knowledge have emphasized the need for appropriate settings in which to
care for the seriously ill infant. Advancements in electronics and biochemistry, new methods for
monitoring cardiorespiratory function, microtechniques for biochemical determination from
minute quantities of blood, noninvasive monitoring, and new methods for assisted ventilation
and conservation of body heat have made it possible to effectively manage the newborn with
serious illness.

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 Intensive care of the ill and immature newborn requires specialized knowledge and skill
in a number of areas. Much of the equipment used in the care of the critically ill adult is unsuited
to the singular needs of the very small infant; therefore equipment has been modified to meet
these needs. Examples of modifications include ventilators that deliver small volumes of oxygen
in the proper concentration and pressure, infusion pumps that accurately deliver very small
amounts, and radiant heat warmers that provide a constant source of warmth and allow
maximum access to the infant. Most important, advances in intensive care have created a need
for highly skilled personnel trained in the art of neonatal intensive care.
The diversity of special care needs requires that the unit be arranged for graduated care of
the infant population. There should be adequate facilities and skilled personnel to provide one-to-
one nursing care for each seriously ill infant, as well as a means for graduation to one-to-three or
one-to-four nursing care in a quieter area where infants require less intensive care until they are
ready to be discharged to home. Family-centered care and a relatively quiet environment are
often difficult to provide in a busy neonatal intensive care unit (NICU); therefore some units
have developed step-down units and single room units where high-risk infants may be observed
by skilled staff. Such areas are designed for family-centered care along with appropriate neuro
developmental care.

ORGANIZATION OF SERVICES
The most efficient organization of services is a regionalized system of facilities within a
designated geographic area. Neonatal intensive care facilities may provide three prescribed levels
of care with special equipment, skilled personnel, and ancillary services concentrated in a

30
centralized institution (American Academy of Pediatrics and American College of Obstetricians
and Gynecologists, 2007):

Level I facility—Provides management of normal maternal and newborn care.

Level IIA facility—Provides a full range of maternity and newborn care and can provide
care to infants born at more than 32 weeks of gestation and weighing more than 1500 g
(3.3 lb) who are moderately ill with problems that are expected to resolve rapidly and
who are not anticipated to need subspecialty care; or who are convalescing after intensive
care.
Level IIB facility—In addition to the above, can provide mechanical ventilation for up to
24 hours and can provide continuous positive airway pressure (CPAP).
Level III facility—Neonatal intensive care
o Level IIIA units provide care for infants with birth weight of more than 1000 g
(2.2 lb) and gestational age of more than 28 weeks. Life support is limited to
conventional mechanical ventilation.
o Level IIIB units can provide care for extremely low–birth weight (ELBW) infants
with technology including high frequency ventilation and inhaled nitric oxide, on-
site access to pediatric medical subspecialists, and advanced diagnostic imaging
and pediatric surgery available.
o Level IIIC units have the capabilities of a level IIIB NICU and, in addition, offer
extracorporeal membrane oxygenation (ECMO) and surgical repair of serious
congenital cardiac malformations.

TRANSPORTING HIGH-RISK NEWBORNS

When an at-risk infant is identified or anticipated, arrangements are made for care in the
intensive care facility. The uterus is the ideal transport unit for the infant with anticipated
difficulties; therefore, whenever possible, take the mother where special care is available for her
delivery.
Some infants develop difficulties after a seemingly normal pregnancy and uncomplicated
labor. Because it is impossible to always predict when infants will require intensive care, a
coordinated System is needed to ensure them an optimum opportunity for survival. Each hospital

31
that delivers infants should be able to provide for appropriate neonatal stabilization and arrange
for transport to a tertiary care facility.
The infant must be kept warm, be adequately oxygenated (including intubation if
indicated), have vital signs and oxygen saturation monitored, and, when indicated, receive an
intravenous (IV) infusion. The infant is transported in a specially designed incubator unit that
contains a complete life-support system and other emergency equipment that can be carried by
ambulance, van, plane, or helicopter.
The transport team may consist of one or more of the highly trained persons from the
NICU: a neonatologist (or a fellow in neonatology), a neonatal nurse practitioner, a respiratory
therapist, and one or more nurses. The professional assigned to accompany the infant must be
constantly alert to every change in the infant’s condition and able to intervene appropriately.
The neonate who must be moved from one place to another within the hospital (e.g., to
surgery, or from delivery room to nursery) is transported in an incubator or radiant warmer and
accompanied by the necessary personnel and equipment.

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NURSING MANAGEMENT

COMMON NURSING DIAGNOSIS

Impaired Gas Exchange

Risk for Fluid Volume Deficit

Risk for impaired Nutrition

Risk for Infection

Risk for Altered Parenting

Diversional Activity Deficit

Risk for Disorganized Infant Behavior

MANAGEMENT OF HIGH RISK INFANT

33
 PHYSICAL ASSESSMENT

THERMOREGULATION- need neutral thermal environment, use brown fat

CONSEQUENCES OF COLD STRESS- hypoxia, metabolic acidosis, hypoglycemia

GLUCOSE & CALCIUM

PROTECT FROM INFECTION

HYDRATION- IVF for calories, electrolytes & H2O

NUTRITION- no coordination of sucking until 32-34 weeks; not synchronized until 36-
37 weeks; gag reflex not developed until 36 weeks

EARLY FEEDING- within 3-6 hours

BREAST FEEDING

GAVAGE FEEDING- <32 wks. or <1500g

SKIN CARE OF PREMATURE- increased sensitivity & fragile

MEDICATION - caution

DECREASE STRESS

DEVELOPMENTAL INTERVENTION

§ BEFORE 33 WEEKS- minimum stimulation

§ 34-36 WEEKS- stimulate senses but don’t tire out

ASSESSMENT OF NEWBORN

34
INTRODUCTION
At birth the newborn is given a cursory yet thorough assessment to determine any
apparent problems and identify those that demand immediate attention. This examination is
primarily concerned with the evaluation of cardiopulmonary and neurologic functions. The
assessment includes the assignment of an Apgar score and an evaluation for any obvious
congenital anomalies or evidence of neonatal distress. The infant is stabilized and evaluated
before being transported to the NICU for therapy and more extensive assessment.
A thorough, systematic physical assessment is an essential component in the care of the
high-risk infant. Subtle changes in feeding behavior, activity, color, oxygen saturation (Spo 2), or
vital signs often indicate an underlying problem. The preterm infant, especially the ELBW
infant, is not able to withstand prolonged physiologic stress and may die within minutes of
exhibiting abnormal symptoms if the underlying pathologic process is not corrected. The alert
nurse is aware of subtle changes and reacts promptly to implement interventions that promote
optimum function in the high-risk neonate.
The nurse notes changes in the infant’s status through ongoing observations of the
infant’s adaptation to the extrauterine environment. Observational assessments of the high-risk
infant are made according to the infant’s acuity (seriousness of condition); the critically ill infant
requires close observation and assessment of respiratory function, including continuous pulse
oximetry, electrolytes, and blood gases. Accurate documentation of the infant’s status is an
integral component of nursing care. With the aid of continuous, sophisticated cardiopulmonary
monitoring, nursing assessments and daily care can be coordinated to allow for minimum
handling of the infant (especially the very low–birth-weight [VLBW] or ELBW infant) to
decrease the effects of environmental stress.

35
 The newborn requires thorough skilled observation to ensure a satisfactory adjustment to the
extrauterine life. Physical assessment following delivery can be divided into 4 phases:

1. The initial assessment using an Apgar scoring system.

2. Transitional assessments during the periods of reactivity.

3. Assessment of gestational age.

4. Systematic physical examination.

INITIAL ASSESSMENT: APGAR SCORING

One significant assessment of the neonate is ‘APGAR SCORING’ as described by DR

Virginia Apgar. Despite its limitations, it is a useful quantitative assessment of neonate’s
condition at birth especially for the respiratory, circulatory and neurological status. Five
objective criteria’s are evaluated at one minute and five minutes, after the neonates body is
completely born. The criteria’s are respiration, heart rate/minute, muscle tone, reflex irritability
and skin color. Each of these criteria is an index of neonates depression or lack of it at birth and
is given score of 0,1 or 2. The scores from each of the criteria are added to determine the total
score. The neonate is the best possible condition if the score is 10. Scores of 7-10 indicate no
difficulty in adjustment in extrauterine life. Scores of 4-6 signify moderate difficulty and if the
score is 3 or below, the neonate is in severe distress which must be treated immediately.

36
 SIGN 0 1 2
HEART RATE absent Slow <100 >100
RESPIRATORY absent Irregular slow weak cry Good strong cry
EFFORT
MUSCLE TONE limp Some flexion of Well flexed
extremities

REFLEX No response Grimace Cry. Sneeze

IRRITABILITY
COLOR Blue, pale Body pink extremities Completely pink
blue
Total score = 10

 No depression : 7-10
 Mild depression : 4-6
 Severe depression : 0-3

TRANSITIONAL ASSESSMENT: PERIOD OF REACTIVITY-

During the initial 24 hours, changes in heart rate respiration, motor activity, color, mucus
production and bowel activity occurs in an orderly, predictable sequence that is normal and
indicates lack of stress.

First period of reactivity:

During the 1st 30 minutes the infant is very active, alert, cries vigorously, sucks the fist
greedily, and appears very interested in the environment. Neonate’s eyes are wide open thus, is
an excellent opportunity for mother, father and child to see each other.

37
Because the newborn has a vigorous suck this is the best time to begin breastfeeding.

Heart rate= 180/mt

Respiration= 80/mt
Bowel sounds are active.

Second stage of first reactive period:

Lasts for 2-4 hours.

Heart rate, respiration decreases.
Temperature continues to decrease. Undressing and bathing is avoided during this time.
Mucus production decreases.
Urine and stool generally not passed.
Baby in a state of sleep and is calm.

38
Second period of reactivity:

Lasts for next 2-5 hours.

Heart rate and respirations increases.
Alert and responsive.
Gastric, respiratory secretions increased.
Passage of meconium frequently.
After this stage is a stage of stabilization of physiologic systems.

ASSESSMENT OF GESTATIONAL AGE

One of the most satisfactory method for predicting mortality risks and providing guidelines
for the management of newborn is the classification of infants at birth by both birth weight and
the gestational age.

 Appropriate for gestational age

 Large for gestational age
 Small for gestational age

Assessment of gestational age is mandatory for all neonates for further management. Last
menstrual period is important clue for calculation of gestational age, but it may not be reliable in
menstrual irregularities or mother may not remember the exact date. The clinical assessment is
more practically significant. Physical and neurological examinations are done to detect the
gestational maturity.

39
 Physical Preterm Transitional Term
Characteristics
Hair texture Wooly fuzzy and very Fine wooly, fuzzy Silky, black coarse and
and fine individual strands
distribution on
scalp
Skin texture Shiny oily plethoric, Less shiny, peripheral Pink, scanty lanugo and
and opacity plenty of lanugo, edema cyanosis, less lanugo and only large veins are
with visible veins and veins are only found on seen. Good elasticity or
venules on abdomen abdomen turgor
Breast nodule Breast tissue less than 5 Breast tissue 5-10 mm More than 10mm
and nipple mm on one or both sides. Nipple present but not diameter
formulation No nipple present raised Breast tissue and nipple
raised above skin level
Ear cartilage Pinna feels soft with no Some cartilage present Pinna is firm with
cartilage and no recoil and some recoil definite cartilage and
instant recoil
Planter creases Faint red marks over Creases seen over anterior Entire sole covered with
1/
anterior part of sole or 3 to ½ of sole deep creases
may be absent
Genitalia Scrotum small with no or Scrotum with some rugae Atleast one testis
[male] few rugae and light and testis in the inguinal descends in the scrotum.
pigmentation. Testis canal Prominent rugae and
usually not descend or in deep pigmentation
inguinal canal
Genitalia Labia majora widely Labia majora partially Labia majora completely
[female] separated with prominent cover over the cover the labia minora
labia minora and clitoris labiaminora and clitoris

Assessment of maturity of the neonates is fairly reliable on the basis of physical

characteristics. But they are of limited value to assess the gestational age in less than 36 weeks of
maturity. The neurological characteristics are more reliable for the precise assessment of
maturity.

40
 The neurological assessment is performed based on four fundamental observations, i.e.
muscle tone, joint mobility, certain automatic reflexes and fundus examination.

The muscle tone of the newborn baby is assessed by three parameters, i.e. posture or attitude,
passive tone [popliteal angle]and scarf sign and active tone [traction response and recoil]

The joint mobility is less in preterm babies. A term baby has more flexible and relaxed joint.
The degree of flexion at ankle and wrist [square-window] is limited due to stiffness of joints in
early gestation.

Certain auto9matic reflexes like moro reflex, papillary response to light, blink response to
glabellar tap, grasp response, neck flexors, rooting reflex with coordinated suckling efforts are
assessed to detect the specific age of gestational maturity based on appearance of these reflexes.

The fundamental examination for disappearance of anterior vascular capsule of lens is done
to assess the gestational age. In infants less than 28 weeks, the anterior capsule is completely
vascularized and after 34 weeks of gestational life, the vessels are almost atrophied. This
examination is difficult due to non-co-operation and photophobia of the neonate.

With the scoring system of the neurological assessment the accurate estimation of gestational
age can be done. New Ballard score is widely used. Neuromuscular maturity is assessed by the
test like posture, square window [wrist], arm recoil, popliteal angle, scarf sign and heel to ear,
using the new Ballard scoring system. Physical maturity is assessed with this system by the
characteristics like skin, lanugo, planter surface, breast, eye/ear and genitals.

TESTS USED IN ASSESSMENT OF GESTATIONAL AGE:

POSTURE:

With infant quite and in supine position, observe degree of flexion in arms and legs.
Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and legs=4

41
SQUARE WINDOW:

With thumb supporting back of arm below wrist, apply gentle pressure with index finger
and third fingers on dorsum of hand without rotating infant’s wrist. Measure angle between base
of thumb and forearm. Full flexion (hand lies flat on ventral surface of forearm)=4

ARM RECOIL:

With infant supine, fully flex both forearms on upper arms, hold for 5 seconds; pull down
on hands to fully extend and rapidly release arms. Observe rapidity and intensity of recoil to a
state of flexion. A brisk return to full flexion=4

POPLITEAL ANGLE:

With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then flex
thigh on abdomen. While holding knee with thumb and index finger, extend lower leg with index
finger of other hand. Measure degree of angle behind knee (popliteal angle). An angle of less
than 90 degrees=5

SCARF SIGN:

With infant supine, support head in midline with one hand; use other hand to pull infant’s
arm across the shoulder so that infant’s hand touches shou7lder. Determine location of elbow in
relation to midline. Elbow does not reach midline=4

HEEL TO EAR:

With infant supine and pelvis flat on a firm surface, pull foot as far as possible up toward
ear on same side. Measure distance of foot from ear and degree of knee flexion (same as
popliteal angle). Knees flexed with a popliteal angle of less than 10 degrees =4

NEW BALLARD SCORING SYSTEM

Neuromuscular maturity is assessed by:

• Posture

• Square window

42
 • Arm recoil

• Popliteal angle

• Scarf sign

• Heel to ear

SUBSEQUENT OR FOLLOW-UP ASSESSMENT IN THE NEONATAL PERIOD

Subsequent assessment is usually done, in institutional delivery, on the first day of birth,
i.e. within 24 hours and within the time of discharge. Daily clinical evaluation should be done,
between first day examination and the day of discharge. Daily clinical evaluation should be done,
between first day examination and the day of discharge. But daily detailed examination is not
necessary because it may introduce infections.

43
First day examinations should include the followings:

General measurements:

For full term infant average head circumference = 33 and 33.5cm.

Chest circumference= 30.5-33cm.
Head to heel length= 48-53 cm
Body weight= 2700-4000g.

Vital signs:

Axillary temperature: 36.5 to 37.6 C( 97.7- 99.7F)

Pulse: 120-140/mt
Respirations: 30-60/mt
Blood pressure: 65/41 mm of Hg

General appearance:

Posture- complete flexion

Behaviour- degree of alertness, drowsiness or irritability to be noted.

PHYSICAL ASSESSMENT:

Skin: Velvetty, smooth and puffy, color depending on the racial and family background.

44
Head: Check the contour. Palpate fontanelles and sutures noting size , shape, molding, or
abnormal [Link] for any cephal hematoma and caput succedaneum. Assess the degree of
head control

Eyes: Edematous lids, purulent discharge from eyes shortly after birth is abnormal. Sclera should
be white and clear.

Ears: Note the position , structure and auditory function. Top of the pinna should lie in
horizontal plane to the outer canthus of eye. Observe startle reflex.

Nose: Sneezing and thin white mucus common.

Mouth and throat:

 Size : small mouth found in trisomy 18 and 21; corners of mouth turn down (fish mouth) in
fetal alcohol syndrome.
 Mucous membranes should be pink.
 Palate examination (hard and soft palate )for closure.

45
  Size of tongue: in relation to mouth normally does not extend much past the margin of
gums. Excessively large tongue seen in congenital anomalies, such as cretinism and
trisomy 21.
 Teeth: pre-deciduous teeth are found on rare occasions; if they interfere with feeding, they
may be removed.
 Epstein's pearls: small white nodules found on sides of hard palate (commonly mistaken for
teeth); regress in a few weeks.
 Frenulum linguae: thin ridge of tissue running from base of tongue along undersurface to
tip of tongue, formerly believed to cause tongue-tie; no treatment necessary. True
congenital ankyloglossia (tongue-tie) is rare.
 Infections : thrush, caused by Candida albicans, may appear as white patches on tongue
and/or insides of
cheeks that do not wash away with fluids; treated with nystatin suspension.

Neck

Examine the following:

 Mobility : infant can move head from side to side; palpate for lymph nodes; palpate
clavicle for fractures, especially after a difficult delivery.
 Torticollis: appears as a spasmodic, one-sided contraction of neck muscles; generally
from hematoma of sternocleidomastoid muscle; usually no treatment required.
 Excessive skin folds may be associated with congenital abnormalities such as trisomy 21.
 Stiffness and hyperextension may be caused by trauma or infection.
 Clavicle for intactness.
 Observe for masses such as cystic hygroma which is soft and usually seen laterally or
over the clavicle.

Chest

 Circumference and symmetry : average circumference is 12 to 13 inches (30 to 33 cm),

approximately 2 cm smaller than head circumference.
 Breast.

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  Engorgement may occur at day 3 because of withdrawal of maternal hormones,
especially estrogen; no treatment required. Regresses in 2 weeks.
 Nipples and areola less formed and pronounced in preterm infants.

Respiratory System

 Rate normally between 40 to 60 breaths/minute; influenced by sleep-wake status, when

last fed, drugs taken by mother, and room temperature.
 Rhythm respirations may be shallow with irregular rhythm.
 Breath sounds,determined by auscultation.

Cardiovascular System

 Rate:normal between 110 to 160 bpm (80 to 110 normal with deep sleep); influenced by
behavioral state, environmental temperature, medication; take apical count for 1 minute.
 Rhythm:common to find periods of deceleration followed by periods of acceleration.
 Heart sounds,second sound higher in pitch and sharper than first; third and fourth sounds
rarely heard; murmurs common, majority are transitory and benign.
 Pulses,examine equality and strength of brachial, radial, pedal, and femoral pulses; lack
of femoral pulses indicative of inadequate aortic blood flow.
 Cyanosis,examine for cyanosis. Acrocyanosis of distal extremities is common; record
location of any cyanosis, color changes with time, and when crying.
 Blood pressure,neonates who weigh more than 3 kg have systolic blood pressure between
60 to 80 mm Hg; diastolic, between 35 and 55 mm Hg. Blood pressure is usually higher
in the lower extremities than in the upper extremities. Blood pressure assessment may not
be conducted routinely on healthy neonates. Measurement of blood pressure is essential
for infants who show signs of distress, are premature, or are suspected of having a cardiac
anomaly.

Abdomen

 Shape,cylindrical, protrudes slightly, moves synchronously with chest in respiration.

 Distension may be caused by bowel obstruction, organ enlargement, or infection.

47
  Palpate abdomen for masses; gap between rectus muscles is common; palpate liver and
spleen.
 Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds occur
an hour after delivery.
 Kidneys palpate kidneys for size and shape.
 Umbilical cord

 Normally contains two arteries, one vein; single artery sometimes associated with
renal and other congenital abnormalities.
 Signs of infection around insertion into abdominal wall-redness, discharge.
 Meconium staining,associated with intrauterine compromise or postmaturity.
 By 24 hours, becomes yellowish brown; dries and falls off in approximately 10 to
14 days.
 Umbilical hernia,defect in abdominal wall.

Genitalia

 Female

 Labia majora cover labia minora and clitoris in full-term female infants.
 Hymenal tag (tissue) may protrude from vagina,regresses within several weeks.
 Vaginal discharge,white mucous discharge common; pink-tinged mucous discharge
(pseudomenstruation) may be present because of the drop in maternal hormones; no
treatment necessary.

 Male

 Full-term,testes in scrotal sac; scrotal sac appears markedly wrinkled due to rugae.
 Edema may be present in scrotal sac if the infant was born in breech presentation; a frank
collection of fluid in the scrotal sac is a hydrocele,regresses in approximately a month.
 Examine glans penis for urethral opening,normally central; opening ventral (hypospadias);
opening dorsally (epispadias); abnormally adherent foreskin (phimosis).

48
 o Check for patent anus,infant should pass stool within 24 hours after delivery. If
passed meconium in utero, patent anus has been established.

Back

Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus; also
for tufts of hair or skin disruptions that would indicate possible spina bifida.
Examine anal area for anal opening, response of anal sphincter, fissures.

Musculoskeletal System

 Examine extremities for fractures, paralysis, range of motion, irregular position.

 Examine fingers and toes for number and separation: extra digits, polydactyly; fused
digits, syndactyly.
 Examine hips for dislocation,with the infant in supine position, flex knees and abduct
hips to side and down to table surface; clicking sound indicates dislocation (Ortolani's
sign).
 Asymmetrical gluteal folds also indicate congenital hip dislocation.
 Examine feet for structural and positional deformities, ie, club foot (talipes equinovarus)
or metatarsus adductus (inward turning of the foot).

Neurologic System

 Neurologic mechanisms are immature anatomically and physiologically; as a result,

uncoordinated movements, labile temperature regulation, and lack of control over
musculature are characteristic of the infant.
 Examine muscle tone, head control, and reflexes.
 Two types of reflexes are present in the neonate:

 Protective in nature (blink, cough, sneeze, gag),remain throughout life.

 Primitive in nature (rooting/sucking, moro, startle, tonic neck, stepping, and palmar/plantar
grasp),either disappear within months or become highly developed and voluntary (sucking
and grasping)

49
BEHAVIORAL ASSESSMENT

Response to Stimulation

Neonates exhibit predictable, directed responses in social interactions with nurturing

adults or in response to attractive auditory or visual stimuli.

Sleeping Pattern

 Length of sleep cycles (REM, active and quiet sleep) changes with maturation of the
central nervous system (CNS).
 Quiet sleep should increase with time in relation to REM sleep.
 Neonates usually sleep 20 hours per day.

Feeding Pattern

 Most neonates feeds 6 to 8 times per day with 2 to 4 hours between feedings; establish
fairly regular feeding patterns in approximately 2 weeks.
 Caloric requirements are high,110 to 130 calories/kg of body weight daily.
 Most digestive enzymes are present at birth.
 Imperfect control of cardiac and pyloric sphincters; immaturity results in regurgitation.

50
Pattern of Elimination

Stool

o Meconium is usually passed in 24 hours.

o Passage of meconium (tarry green-black stools) continues for 48 hours, followed
by transitional stools (combination of meconium and yellow or milk stools). Milk
stools (yellow) are passed by day 5.
o Neonate has up to six stools per day in the first weeks after birth.

Voiding

o Neonate voids within first 24 hours.

o After first few days, infant voids from 10 to 15 times per day.

Temperature Regulation

 Infant's body responds readily to changes in environmental temperature.

 Heat loss at birth may occur through evaporation, convection, conduction, and radiation.
 Physiologic mechanisms to avoid heat loss include:

o Vasoconstriction.
o Nonshivering thermogenesis elicited by sympathetic nervous system in response
to decreased temperature.

REFLEXES OF NEWBORN

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PRIMITIVE REFLEX

Primitive reflexes are reflex actions originating in the central nervous system that
are exhibited by normal infants but not neurologically intact adults, in response to particular
stimuli. These reflexes disappear or are inhibited by the frontal lobes as a child moves through
normal child development. These primitive reflexes are also called infantile, infant or newborn
reflexes.

ADAPTIVE VALUE OF REFLEXES

Reflexes vary in utility. Some have a survival value. A perfect example would be the
rooting reflex, which helps a breastfed infant find the mother's nipple. Babies display it only
when hungry and touched by another person, not when they touch themselves. There are a few
reflexes that probably helped babies survive during human evolutionary past like the Moro
reflex.

Other reflexes such as sucking and grabbing help establish gratifying interaction
between parents and infants. They can encourage a parent to respond lovingly and feed more
competently. They can also help parents comfort their infant because they allow the baby to
control distress and the amount of stimulation they receive.

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ROOTING REFLEX

The rooting reflex is present at birth: it assists in breastfeeding, disappearing at

around four months of age as it gradually comes under voluntary control.

A newborn infant will turn his head toward anything that strokes his cheek or
mouth, searching for the object by moving his head in steadily decreasing arcs until the object is
found. After becoming used to responding in this way (if breastfed, approximately three weeks
after birth), the infant will move directly to the object without searching.

Rooting reflex

SUCKING REFLEX

The sucking reflex is common to all mammals and is present at birth. It is linked
with the rooting reflex and breastfeeding, and causes the child to instinctively suck at anything
that touches the roof of their mouth and suddenly starts to suck simulating the way they naturally
eat. There are two stages to the action:

Expression: activated when the nipple is placed between a child's lips and touches their palate.
They will instinctively press it between their tongue and palate to draw out the milk.

Milking: The tongue moves from areola to nipple, coaxing milk from the mother to be
swallowed by the child.

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GRASP

This reflex is shown by placing finger or an object into baby's open palm, which will
cause a reflex grasp or grip. If it is tried to pull away, the grip will get even strong. The palmar
and plantar grasp usually disappears by 5-6 months and 9-12 months respectively.

Palmar grasp reflex

PLANTAR REFLEX

A plantar reflex is a normal reflex that involves plantar flexion of the foot (toes move
away from the shin, and curl down.

BABINSKI REFLEX

An infant demonstrating the Babinski reflex: he opens his mouth when pressure is
applied to both palms (8 seconds).

The Babinski reflex occurs in newborn babies, and describes varying responses to
the application of pressure to both palms. Infants may display head flexion, head rotation or
opening of the mouth, or a combination of these responses. Smaller, premature infants are more
susceptible to the reflex.

MORO REFLEX

Also called the startle reflex, the Moro is usually triggered if baby is startled by a
loud noise or if his head falls backward or quickly changes position. Baby's response to the
moro will include spreading his arms and legs out widely and extending his neck. He will then
quickly bring his arms back together and cry. The moro reflex is usually present at birth and
disappears by 3-6 months.

54
 STARTLE REFLEX

The Moro reflex in a four-day-old infant: 1) the reflex is initiated by pulling the infant up
from the floor and then releasing him; 2) he spreads his arms 3) he pulls his arms in; 4) he cries
(10 seconds)

MORO REFLEX

WALKING/ STEPPING REFLEX

The walking or stepping reflex is present at birth; though infants this young can not
support their own weight, when the soles of their feet touch a flat surface they will attempt to
'walk' by placing one foot in front of the other. This reflex disappears at 6 weeks as an automatic
response and reappears as a voluntary behavior at around eight months to a year old

55
 WALKING/STEPPING REFLEX

TONIC NECK REFLEX

The tonic neck reflex, also known as asymmetric tonic neck reflex or 'fencing posture'
is present at one month of age and disappears at around four months. When the child's head is
turned to the side, the arm on that side will straighten and the opposite arm will bend (sometimes
the motion will be very subtle or slight). According to researchers, the tonic neck reflex is a
precursor to the hand/eye coordination of the infant. It also prepares the infant for voluntary
reaching.

TONIC NECK REFLEX

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Opposite reaction Tonic Neck Reflex

A postural reaction, the asymmetric tonic neck reflex, or fencer response, is present at
birth. To elicit this reflex, while your baby is lying on his back, turn his head to one side, which
should cause the arm and leg on the side that he is looking toward to extend or straighten, while
his other arm and leg will flex. This reflex usually disappears by 4-9 months.

GALANT REFLEX

If your baby is on his stomach and you stroke neck to the spinal cord (paravertebral
area) on his middle to lower back, it will cause his back to curve towards the side that you are
stroking. This reflex is present at birth and disappears by 3-6 months. If the reflex persists past
six months of age, it is a sign of pathology. The reflex is named after the Russian neurologist
Johann Susman Galant.

SWIMMING REFLEX

An infant placed face down in a pool of water will begin to paddle and kick in a
swimming motion. The reflex disappears between 4–6 months. Its survival function is to help the
child stay alive if it is drowning so a caregiver has more time to save it.

DOLL’S EYE REFLEX

Eyes open on coming to sitting (Like a Doll's) Head initially lags Baby uses shoulders
to right head position

PROTECTIVE REFLEX

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 1. Soft cloth is placed over the babies eyes and nose
2. Baby arches head and turns head side to side
3. Brings both hands to face to swipe cloth away

CRAWLING REFLEX

Newborn placed on abdomen

Baby flexes legs under him and starts to craw

PARACHUTE RESPONSE

This is a protective response that protects infant if he falls. Beginning at about 5-6
months, if an infant falls, he will extend his arms to try and 'catch' himself.

PROPPING

Beginning at different ages, the propping responses help child learn to sit. The first is
the anterior propping response, which begins at 4-5 months, and involves infant extending his
arms when he is held in a sitting position, allowing him to assume a tripod position.

Next, lateral propping, appearing at 6-7 months, causes him to extend his arm to the side
if he is tilted.

Lastly, posterior propping, causing him to extend his arms backwards if he is titled
backward.

DAILY OBSERVATION OF NEONATES:

Neonates should be observed daily during hospital stay. Detailed examination is not
necessary but mother and baby should be approached two times daily and informations should be
collected from the mother (or caretaker) about the feeding behavior, vomiting, passage of stool
and urine, sleep and presence of any problems. The neonates should also be assessed for
hypothermia, respiratory distress, jaundice and superficial infections like conjunctivitis,
umbilical sepsis, oral thrush and skin infection.

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 The neonates should be monitored for the danger signs. Presence of these features
indicates special attention, reevaluation and early interventions.

The danger signs are:

 Poor feeding, sucking and swallowing reflex.

 Cold to touch or having rise in body temperature
 Poor activity and poor response to stimulation
 Excessive crying and irritability
 Rapid respiration, more than 60 per minutes and presence of chest retractions
 Blue discoloration of lips or tongue (central cyanosis)
 Drooling of saliva or chocking during feeding or frothiness
 Labored respiration or absence of respiration
 Jaundice appears within 24 hours one extending to palms or soles
 No urine within 48 hours and no meconium within 24 hours
 Convulsions or abnormal movements
 Bleeding from any site
 Umbilical discharge
 Superficial infections (pyoderma, abscess, oral thrush, conjunctivitis)
 Diarrhea, vomiting and abdominal distension.

NEONATAL INTENSIVE CARE UNIT GOALS AND OBJECTIVES

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GOAL 1: Understand the pediatrician’s role in reducing morbidity in high risk pregnancies and
complications of childbirth.

OBJECTIVES

Describe general principles about:

o Basic vital statistics that apply to newborns (neonatal, perinatal mortality,etc.)
o Tests commonly used by obstetricians to measure fetal well-being.
o Prenatal services available in one’s region.
o Prenatal visit in the pediatrician’s office.
o Neonatal transport systems
o Effective intervention programs for teens and other high risk mothers

For each of the following prenatal and perinatal complications

o Describe the pediatrician’s role in assessment and management.
o Recognize potential adverse outcomes for the fetus/neonate

List of complications:
o Maternal infections/exposure to infections during pregnancy
o Fetal exposure to harmful substances (ETOH, TOB, street drugs, medications,
environment toxins)

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 o Maternal insulin-dependent diabetes and pregnancy-induced glucose
intolerance
o Premature labor, premature ruptured membranes
o Complications of anesthesia and common delivery practices (Cesaerean section,
vacuum, forceps, epidural, induction of labor)
o Fetal distress during delivery
o Postpartum maternal fever/infection
o History of maternal GBS colonization/treatment
o Multiple gestation
o Placental abnormalities
o Pre-eclampsia, eclampsia PL 2,3l. Chorioamnionitis
o Polyhydramnios
o Oligohydramnios

Discuss the pediatrician’s role in reducing fetal and neonatal morbidity/mortality ihis/her
own community.

GOAL 2: Understand how to resuscitate and stabilize a critically ill neonate.

OBJECTIVES
Describe the steps in resuscitation and stabilization, including equipment needed.
Demonstrate efficient and effective resuscitation in mock codes and under stress of actual
codes.
Formulate a differential diagnosis for serious symptoms presenting during transfer to the
NICU or in the NICU immediately after resuscitation.

GOAL 3: Understand how to evaluate and manage common signs and symptoms of disease in
high risk newborns.

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OBJECTIVES

For each of the signs and symptoms below:

1. Perform an appropriate assessment (H&P, Initial diagnostic studies).

2. Formulate a differential diagnosis with appropriate prioritization
3. Describe indications for admission or referral to Levels I, II, and III nurseries.
4. Describe stabilization procedures to prepare for transfer
5. Formulate and carry out a plan for continuing assessment and management.

List of Signs and Symptoms (NICU)

General:
 Intrauterine growth failure
 Large for gestational age
 Hypothermia
 Hyperthermia,
 Prematurity
 Feeding problems
 Poor postnatal weight gain
 Lethargy/irritability/jitteriness,
 History of maternal infection or exposure,
 Dehydration.

Cardiorespiratory
§ Respiratory distress
§ Cyanosis
§ Apnea
§ Bradycardia
§ Heart murmur
§ Hypotension
§ Hypotension

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 § Hypovolemia
§ Poor pulses
§ Shock.

Dermatologic:
 Common skin rashes/conditions,
 Birthmarks
 Hyper and hypopigmented lesions
 Discharge and/or inflammation of the umbilicus
 Proper skin care for premature infants
 Vesicles.

Gastro Intestinal/Surgical:
 Feeding intolerance
 Vomiting,
 Bloody stools
 Distended abdomen,
 Hepatosplenomegaly
 Abdominal mass
 Failure to pass stool
 Diarrhea.

Genetic/Metabolic:
 Metabolic derangements,
 Hypoglycemia
 Hypercalcemia
 Hypocalcemia,
 Hypokalemia
 Hyperkalemia
 Apparent congenital defect or dysmorphic syndrome.

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Hematologic:
 Jaundice in a premature, term or seriously ill neonate,
 Petechiae
 Anemia,
 Polycythemia
 Abnormal bleeding,
 Thrombocytopenia
 Neutropenia.

Musculoskeletal
 Birth trauma related fractures and soft tissue injuries
 Dislocations
 Birth defects and deformities.
 Neurologic
 Hypotonia
 Hypertonia
 Seizures,
 Lethargy
 Early signs of neurologic impairment,
 Microcephaly, macrocephaly
 Spina bifida
 Birthtrauma related nerve damage.

Parental Stress/Dysfunction
Poor attachment,
Postpartum depression
Anxiety disorders
Teen parent
Substance abuse
Child abuse and
Neglect.

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Renal/Urologic
 Edema
 Decreased urine output
 Abnormal genitalia
 Renal mass
 Hematuria,
 Urinary retention
 Inguinal hernia.

Ophthalmologic
 Abnormal red reflex
 Eye anomaly

GOAL 4: Understand how to manage, under the supervision of a neonatologist, common

diagnoses in infants in a Level II or III nursery.

OBJECTIVES

For each of the following common diagnoses in the list below; be able to
o Describe the pathophysiologic basis of the disease.
o Describe the initial assessment plans.
o Discuss key principles of the NICU management plan.
o Explain when to use consultants.
o Explain the role of the primary care provider.

List of Common Diagnoses in this Setting (NICU)

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Pulmonary disorders: Hyaline membrane disease, transient tachypnea of the newborn,
meconium aspiration, amniotic fluid or blood aspiration, persistent pulmonary hypertension,
pneumonia, pneumothorax, bronchopulmonary dysplasia, atelectasis.

Cardiac conditions: Congenital heart disease (cyanotic and acyanotic, obstructive lesions,
single ventricle), patent ductus arteriosus, congestive heart failure, SVT, complete heart block.

Genetic, endocrine disorders: Infant of diabetic mother, common chromosomal anomalies,

congenital adrenal hyperplasia, hypo and hyperthyroidism.

GI/nutrition: Feeding plans and nutritional management of high risk neonates or those with
special needs, breast feeding support for mothers and infants with special needs, hepatitis,
gastrointestinal reflux, meconium plug, malrotation, Hirschprungs, necrotizing enterocolitis,
short gut syndrome, gastroesophageal reflux.

Hematologic conditions: Indications for phototherapy, anemia, polycythemia, transfusion of

blood products, exchange transfusions in the premature/term or ill neonate, erythroblastosis
fetalis/hydrops fetalis, coagulopathy, hemophilia, Vitamin K prophylaxis/deficiency.

Infectious disease: Intrauterine viral infections, Group B Streptococcal infections, neonatal

sepsis and meningitis, herpes simplex; infant of HIV infected mothers, neonatal hepatitis,
syphilis; nosocomial infections in the NICU, central line infections, immunization of the
premature neonate, isolation procedures for contagious diseases in mother/infant, indications for
RSV prophylaxis.

Neurologic disorders: Hypoxic-ischemic encephalopathy, intraventricular hemorrhage, hearing

loss in high risk newborns, drug withdrawal, seizures, hydrocephalus, spina bifida, CNS
anomalies.

Surgery: (assess and participate in management under supervision of or collaboration with

pediatric surgeon) Necrotizing enterocolitis, short gut syndrome, intestinal perforation, intestinal

66
obstruction, diaphragmatic hernia, malrotation, esophageal atresia and tracheoesophageal fistula,
intestinal atresia, meconium ileus, meconium plug syndrome, gastroschisis, omphalocele,
imperforate anus, pre-op and post-op care.

Eye disorders: retinopathy of prematurity, cataracts and eye anomalies

Miscellaneous: complications of umbilical catheterization

GOAL 5: Understand how to use and interpret laboratory and imaging studies unique to the
NICU stetting.

OBJECTIVES
Order and interpret laboratory and imaging studies appropriate for NICU patients.
Explain indications, limitations, and gestational-age norms for the following which may
have specific application to neonatal care:
o Serologic and other studies for transplacental infections
o Direct and indirect Coomb’s test
o Neonatal drug screening
o Neuro ultrasound
o Abdominal x-rays for placement of umbilical catheter, bowel gas pattern,
evidence of NEC
o Chest x-rays for endotracheal tube placement, heart size and vascularity, deep line
placement

GOAL 6: Understand the application of the physiologic monitoring and special technology
applied to the care of the fetus and newborn

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OBJECTIVES
For each of the following, which are commonlyused by pediatricians, discuss indications
and limitations and demonstrate proper use/instruction in how to use:
o Physiologic monitoring of temperature, pulse, respiration, blood pressure
o Phototherapy
o Pulse oximetry
o Umbilical arterial and venous catheterization
o Endotracheal intubation
o Thoracentesis
o Chest tube placement
o Electric and manual breast pumps
From each of the following techniques and procedures used by obstetricians,
perinatalologists, and neonatologists, describe key indications, limitations, normal and
frequently encountered abnormal findings, and common complications for the
fetus/infant:
o Fetal ultrasound for size and anatomy
o Fetal heart rate monitors
o Scalp and cord blood sampling
o Surfactant therapy
o ECMO/Nitric oxide therapy
o Amniocentesis
o Biophysical profile/stress testing
o Intrauterine transfusions/PUBS
o Chorionic villus sampling
o Exchange transfusion
o Central hyperalimentation
Discuss in general terms, home medical equipment and services needed for oxygen
dependent and technology dependent graduates of the NICU.

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GOAL 7: Develop a logical and effective approach to the assessment and daily management of
seriously ill neonates and their families, under the guidance of a neonatologist, using decision-
making and problem solving skills.

OBJECTIVES
Apply principles of decision-making and problem solving to care in the NICU.
Seek information as needed and apply this knowledge appropriately using evidence
baseproblem solving.
Recognize the limits of one’s own knowledge, skill, and tolerance of stress; know when
to afor help, how to contact consultants and where to find basic information.
Develop a comprehensive problem list with appropriate and accurate prioritization for
action.

GOAL 8: Understand how to function effectively as part of an interdisciplinary team member in

the NICU.

OBJECTIVES
Communicate and work effectively with all members of the healthcare team (residents,
attending, consultants, nurses, nurse specialists, lactation consultants, nutritionist,
pharmacists, respiratory therapist, social workers, discharge coordinators, referring
physicians and ancillary Staff).
Communicate effectively with parents of critically ill patients and highly stressed
families.
Discuss role of primary care physician in the long term management of infants admitted
to the NICU.
Discuss the role of managed care case manager, work with these individuals to optimize
healthcare outcomes.

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GOAL 9: Understand how to provide comprehensive and supportive care to the NICU infant
and their family.

OBJECTIVES
Serve effectively as an advocate and case manager for patients with multiple problems or
chronic illnesses.
Work with discharge coordinator to develop discharge plans which facilitate the family’s
transition to home care, including adequate follow-up and appropriate use of community
services.
Demonstrate sensitivity and skills in dealing with death and dying in the NICU setting.
Consistently listen carefully to concerns of families and provide appropriate information
and support.
Provide counseling and support for breast feeding of premature and critically ill infants,
including maintenance of mother’s milk supply when the infant cannot suckle.
Provide responsible communication with the neonate’s primary care physician during the
hospital stay and in discharge planning.
Identify problems and risk factors in the infant or family and make appropriate
interventions and/or referrals.

GOAL 10: Become familiar with ethical and medical-legal consideration in the care of critically
ill newborns.

OBJECTIVES
Discuss concepts of futility, withdrawal and withholding care.
Describe hospital policy on “Allow Natural Death” orders.
Identify situations warranting consultation with the hospital ethics committee.
Complete a death certificate appropriately.

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GOAL 11: Understand key aspects of cost control and mechanisms for payment in the NICU
setting

OBJECTIVES
Be sensitive to the burden of costs on families and refer for social services as indicated.
Use consultants and other resources appropriately during NICU stay and in discharge
planning.
Demonstrate awareness of costs and cost control in NICU care.
Explain principles of typical coverage by local insurance plan, Medical, and other state
and federal subsidies for the care of high risk neonates.

GOAL 12: Understand how to maintain accurate, timely and legally appropriate medical
records in the critical care setting of the NICU.

OBJECTIVES
Ensure that initial history and physical examination records include appropriate history,
exam appropriate for the infant’s condition, record of procedures in delivery room and
since admission; problem list assessment and plan.
Maintain daily timed notes, with updates as necessary, clearly documenting the patient’s
progress and details of the on-going evaluation and plan.
Ensure discharge summary is timely and concise, with clear documentation of discharge
plans and follow up appointments.

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RESEARCH ARTICLE

1. HEARING SCREENING IN HIGH RISK NEWBORNS AND RESEARCH OF

HIGH RISK FACTORS OF HEARING LOSS IN NEWBORNS.

[Article in Chinese]
Chen Y, Zhang Y, Guo Q, Ye C, Peng S.

Source

Department of Otolaryngology, Affiliated Hospital of Dali University, Dali, 671000, China.

chenyinzhong96224@[Link]

Abstract
OBJECTIVE:
To identify the newborns who should receive hearing evaluation by hearing screening in
high risk newborns; to find and confirm the high risk factors of hearing disorders in high risk
newborns.

METHOD:
The first screening was performed by DPOAE. Newborns did not passed the first
screening undertook second screening using DPOAE + ABR. and newborns did not passed the
second screening received hearing evaluation. High risk factors of hearing loss were found by
Logistic regression analysis.

RESULT:

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 Three hundred and twenty-seven cases were screened. The positive ratio in first screening
was 37.0%. The positive ratio in second screening was 11.0%. Ten cases were diagnosed as
hearing loss and the incidence of hearing loss was 3.39%. High risk factors of hearing loss were
asphyxiation, very low born weight (<1,500 g) and head and neck abnormality.

CONCLUSION:
(1) DPOAE combined with ABR is credible and feasible in hearing screening of high risk
newborns. (2) High risk factors of hearing loss were asphyxiation, very low born weight (<1,500
g) and head and neck abnormality in this study.

2. LONG TERM NEUROLOGICAL OUTCOME OF HIGH RISK INFANTS

Authors:
1. Selzer, S C
2. Lindgren, S D
3. Blackman, J A

Abstract:
Evaluated long-term neuropsychological outcome of 20 high risk infants with intracranial
hemorrhage (ICH) during the neonatal period who appeared free of significant impairment
through 30 months of age. This group was compared with a matched sample of 20 high risk
infants without intracranial hemorrhage and a group of 70 children with no history of perinatal or
chronic health problems. A comprehensive neuropsychological evaluation at age 5 revealed that
the two high risk groups tended to perform at a lower level than the control group across most
measures. However, the ICH group performed at a significantly lower level than the control
group on measures of perceptual-motor skills and intermodal memory abilities while the high
risk group without ICH did not. The implications of differences in level and pattern of
performance are discussed along with the implications of the current findings for long-term
functioning of high risk infants with ICH.

SUMMARY

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 High-risk neonates may be defined as newborns, regardless of gestational age or birth
weight, who have a greater than average chance of morbidity or mortality because of conditions
or circumstances superimposed on the normal course of events associated with birth and
adjustment to extrauterine existence. Identification of high-risk newborns may occur during any
of the following stages: prenatal, natal, or postnatal.
High-risk infants may be classified according to birth weight, gestational age, and morbidity
factors. Meeting the high-risk infant’s nutritional needs requires specific knowledge of
physiologic characteristics, the infant’s particular needs, and methods of feeding. Delayed
development in high-risk neonates is a concern; developmental interventions are individualized
to ameliorate the effects and increase infant well-being.
Parental involvement in the care of high-risk infants is important, and nurses should
encourage parent-infant relationships from birth to discharge.
Prematurity accounts for the largest number of admissions to an NICU. Nurses play an
important role in end-of-life care of the family of the dying infant.

CONCLUSION

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 Some newborns are considered high risk. This means that a newborn has a greater chance
of complications because of conditions that occur during fetal development, pregnancy
conditions of the mother, or problems that may occur during labor and birth.

Some complications are unexpected and may occur without warning. Other times, there
are certain risk factors that make problems more likely.

Fortunately, advances in technology have helped improve the care of sick newborns.
Under the care of specialized physicians and other healthcare providers, babies have much
greater chances for surviving and getting better today than ever before.

BIBLIOGRAPHY

 Meharban Singh, Care of Newborn. 6th ed. Jaypee brothers medical publisher,pvt ltd
,New Delhi.

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  [Link], Book of neonatology principles and practice ,2 nd edition,Jaypee brothers
medical publisher,pvt ltd ,New Delhi,page no-30-37.
 Hockenberry JM, Wilson D Wong’s nursing care of infant’s and children. 8 th ed.
Missouri: Elsevier; 2007. p.271-80

 Marlow RD Textbook of paediatric nursing. 6th ed. Pennsylvania: Elsevier; 2007.p.250-8.

 Pilliteri A Child health nursing. 1st ed. Philadelphia: Lippincott;1999.p.432-8.

 Parthasarathy A IAP textbook of paediatrics. 3rd ed. New Delhi: Jaypee;2006.p.442-6.

 Dutta AK, Sachdeva A Advances in paediatrics. 1st ed. New Delhi: Jaypee;2007.p.89-96.

 Ghai OP, Gupta P, Paul VK Ghai essential paediatrics. 6 th ed. New Delhi: CBS;
2005.p.166-9.

RESEARCH ARTICLE

Chen Y, Zhang Y, Guo Q ‘Hearing Screening In High Risk Newborns And Research Of
High Risk Factors Of Hearing Loss In Newborns’. Department of Otolaryngology,
Affiliated Hospital of Dali University. 2010. Jan. Volume 19. 753-89.

Selzer, S C, Lindgren, Blackman. ‘Long Term Neurological Outcome Of High Risk

Infants’. Institute for Clinical and Translational Science: Elsevier publications.
[Link] , Sep 2,
2011.

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