High-Risk Newborn Care: Respiratory Support

High Risk Newborn

• Newborn priorities in the first days of life involve initiation and maintenance of respiration
• Also: establishing extrauterine circulation, fluid and electrolyte balance, controlling body temperature, adequate nutrition
• Focus: waste elimination, infection prevention, and establishing an infant-parent/caregiver relationship
• Institution of developmental care balances physiologic needs and stimulation

Initiating & Maintaining Respiration

• Infants struggling to breathe may experience lasting neurological issues from cerebral hypoxia
• Respiratory defense mechanisms start immediately after birth to prevent severe acidosis.
• Infants with asphyxia from: cord compression, maternal anesthesia, placenta previa, IUGR, or premature separation may have acidosis at birth
• Shunt failure, particularly of the ductus arteriosus, is a concern when respirations are ineffective

Factors Predisposing Infants to Respiratory Difficulty

• Low birth weight
• Intrauterine growth restriction
• Maternal history of diabetes
• Premature rupture of membranes
• Maternal use of barbiturates or narcotics close to birth
• Meconium staining
• Irregularities detected by fetal heart monitoring during labor
• Cord prolapse
• Lowered Apgar scoring
• Post-maturity
• Small for gestational age
• Breech birth
• Multiple birth
• Chest, heart, or respiratory tract anomalies
• 10% of newborns need help to begin breathing at birth

The Preterm Infant

• Preterm infants are live-born before the end of the 37th week.
• They often need intensive care and are vulnerable to hypoglycemia and intracranial hemorrhage
• Prone to respiratory distress syndrome due to a lack of lung surfactant which doesn't form until about the 34th week of pregnancy
• Preterm infants appear immature and have low birth weight

Common Factors Associated with Preterm Birth

• Low socioeconomic level
• Poor nutritional status
• Lack of prenatal care
• Multiple pregnancy
• Previous early birth
• Race (higher among non-whites)
• Cigarette smoking
• Age of the mother (younger than 20 years old)
• Order of birth
• Closely spaced pregnancies
• Abnormalities of the mother’s reproductive system, like intrauterine septum
• Infections (UTI)
• Pregnancy complications such as premature rupture of membranes
• Early induction of labor
• Elective caesarean birth

Assessment of a Preterm Infant

• Head appears disproportionately large
• Skin is unusually ruddy with little subcutaneous fat, veins easily noticeable, and higher degree of cyanosis
• Vernix is lacking
• Lanugo is scant
• Fontanelles: Anterior and posterior are small
• Feet: Few or no crease on the soles
• Eyes: Appear small, degrees of myopia
• Ears: Appear large in relation to head, allows pinna to fall forward
• Breast Tissue: Areola and nipple are barely visible (34 weeks)

Resting Posture

• Characterized by very little flexion in the upper extremities and only partial flexion of the lower extremities

Male Genitalia

• Testes are very high in the inguinal canal, with few rugae on the scrotum
• Full-term infant testes are lower in the scrotum with many rugae

Female Genitalia

• Premature female has hips abducted
• Clitoris is prominent and labia majora are very small and separated.
• In a full term infant, the Labia minora and clitoris are covered by the labia majora

Potential Complications

• Anemia of prematurity
• Acute bilirubin encephalopathy
• Persistent patent ductus arteriosus

Acute Bilirubin Encephalopathy

• Destruction of brain cells by invasion of indirect bilirubin
• Invasion results from high concentration of indirect bilirubin that forms in the bloodstream from excessive breakdown of red blood cells at birth
• Preterms have less serum albumin available to bind bilirubin
• Phototherapy or exchange transfusion is initiated when jaundice occurs to prevent high levels of bilirubin

Periventricular/Intraventricular Hemorrhage

• Preterm infants prone to bleeding due to fragile capillaries and immature cerebral vascular development
• Important to maintain a neutral thermal environment and monitor serum hematocrit (45% - 65%)
• Assess prenatal history for toxoplasmosis, rubella, CMV, and herpes simplex infections and use isolation precautions
• Provide education and emotional support

Nursing Diagnosis

• Impaired gas exchange related to immature pulmonary function
• Risk for imbalanced nutrition, related to more nutrients needed for rapid growth, sucking difficulty, and small stomach
• Ineffective thermoregulation
• Risk for impaired parenting related to the infant’s hospitalization
• Deficient diversional activity related to the infant’s need for rest
• Risk for disorganized infant behavior related to prematurity and environmental overstimulation

Post Term Infant

• Dry, cracked, leather-like skin, lack of fluid, and absence of vernix
• Meconium stained
• Grown fingernails
• Demonstrates alertness
• Difficulty establishing respiration
• Polycythemia
• Elevated haematocrit
• Hypoglycemia in the first hour of life
• Temperature regulation difficult
• Higher morbidity and mortality due to perinatal asphyxia and meconium aspiration syndrome

Small for Gestational Age (SGA) Infant

• SGA is also called microsomia
• Birth weight below the 10th percentile on an intrauterine growth curve
• SGA is small because of intrauterine growth restriction (IUGR).

Etiology of SGA

• Mother’s nutrition
• Partial placenta separation with bleeding
• Severe diabetes mellitus or gestational hypertension
• Women who smoke heavily
• Women who use opiates

Signs and Symptoms of SGA

• Poor skin turgor
• Head appears large compared to the rest of the body
• Skull sutures may be widely separated
• Hair may be dull and lusterless
• Abdomen may be sunken
• Umbilical cord appears dry and may be stained yellow

Laboratory Findings for SGA

• High hematocrit level
• Increase in total number of RBCs
• Hypoglycemia

Nursing Diagnosis for SGA

• Ineffective breathing pattern related to underdeveloped body systems at birth
• Risk for ineffective thermoregulation related to lack of subcutaneous fat
• Risk for impaired parenting related to child’s high-risk status and possible cognitive or neurologic impairment

Large for Gestational Age (LGA) Infant

• Newborn babies who weigh more than usual for the number of weeks of pregnancy

• Means babies who weigh more than 9 in 10 babies (90th percentile) or more than 97 of 100 babies (97th percentile) of the same gestational age

• LGA infants be be identified to ensure they given care appropriate to their gestational age

Causes of LGA

• Large newborns may be normal due to large parents
• Diabetes in the mother
• Maternal obesity
• Having had previous LGA babies
• Genetic abnormalities or syndromes (Beckwith-Wiedemann syndrome or Sotos syndrome)
• Excessive weight gain during pregnancy

Symptoms of LGA

• Weigh more than 9 in 10 babies or 97 of 100 babies of the same gestational age
• In the US, babies born at 40 weeks' gestation weigh more than 8 pounds 13 ounces (4,000 grams) or 9 pounds, 11 ounces (4,400 grams)

Clinical Appearance

• Immature reflexes
• Low score on gestational exam
• Extensive bruising or birth injury
• Caput succedaneum
• Cephalhematoma
• Molding

Complications of LGA

• Birth injuries
• Difficult delivery
• Low Apgar Score
• Perinatal asphyxia
• Meconium aspiration
• Low blood sugar (glucose) levels (hypoglycemia)
• Lung problems
• Birth defects: excess red blood cells (polycythemia)

Nursing Diagnosis for LGA

• Ineffective breathing pattern related to possible birth trauma in the LGA newborn
• Risk for imbalanced nutrition, related to additional nutrients needed and prevent hypoglycemia
• Risk for impaired parenting related to high risk status of LGA infant

Respiratory Distress Syndrome (RDS)

• Formerly "hyaline membrane disease"
• Common in premature babies

Premature Babies at risk for RDS

• Male gender
• White ethnicity
• Sibling born with RDS
• C-section, especially without labor
• Inadequate oxygen
• Trouble maintaining body temperature
• Infection
• Twin or other multiple
• Maternal diabetes.

Causes of RDS

• Occurs when there is not enough surfactant in the lungs
• Surfactant is liquid makes it possible for babies to breathe in air
• Alveoli collapse since there's less surfactant causing cell damage that builds up in the air ways
• Affected cell further affects breathing
• Baby works hard to attempt to breathe but alveoli collapses
• Baby intakes less oxygen and thus more carbons builds up in the blood
• This may increase acid levels in the blood and damage other organs

How is RDS Diagnosed

• Baby's breathing efforts and appearance
• Tests done include: chest x-rays, blood and echo

Symptoms of RDS in Premature Babies

• Low body temperature
• Nasal flaring
• Sternal and subcostal retractions
• Tachypnea (more than 60lbreaths/min)
• Cyanotic mucous membrane
• Seesaw respiration
• Heart failure
• Pale gray skin
• Periods of apnea
• Bradycardia
• Pneumothorax

Treatment for RDS

• Placing a breathing tube into your body’s windpipe
• Ventilation
• Extra Oxygen
• Extra Air Pressure
• Surfactant

Possible Complications

• Air leaks in the chest,
• There may be chronic lung infection

Prevention

• Preventing premature birth
• Steriods can be given to women for early delivery to lower the risk

Transient Tachypnea of the Newborn

• Mild, short-lived breathing problem.
• Affects babies within the first hours of life
• Marked by fast breathing
• Symptoms usually resolve in 3 days without treatment.

Contributing Factors

• Presence of fluid in the lungs resulting from hormone changes before birth
• The absence of process where the fluid is absorbed into lungs

Identifying High Risk Patients

• Full-term babies or babies delivered via C-Section
• Moms with asthma and/or diabetes

Symptoms of Tachypnea

• Rapid breathing rate of more than 60 bpm
• Grunting sounds
• Nostril flaring
• Pulling in at the ribs
• Overinflated lungs from x-ray

Treatment for Tachypnea

• Supplemental oxygen
• Continuous positive airway pressure
• IV fluid
• Tube feeding

Meconium Aspiration Syndrome

• Respiratory distress in a newborn from aspirating meconium into the lungs.
• Meconium Aspiration occurs when stress causes fetus to gasp causing meconium to be breathed (aspirated) deposited into the lungs
• Air ways may become blocked and causes regions of the lungs to collapse

Symptoms of Meconium Aspiration

• Respiratory distress
• Grunting
• Bluish Skin or Lips
• Low blood pressure
• Greenish tint

Treatment for Meconium Aspiration

• Measures to surfactant and antibiotics
• Treatment of any underlying disorder

Causes, Prevention and Treatment of Sudden Infant Death Syndrome (SIDS)

• SIDS is the unexplained death, usually during sleep of a seemingly healthy baby less than a year old
• SIDS is sometimes known as crib death because the infants often die in their cribs
• Peak age of incidence is 1–4 months of age

Risk Factors

• Adolescent mothers, closely spaced pregnancies, underweight and preterm infants are at a higher risk
• Twins, Native American infants, Alaskan native infants and/or Economically disadvantage black infants are at a higher risk
• Infants of narcotic mothers

Contributing Factors

• Sleeping supine
• Viral/ Botulism
• Exposed to second-hand smoke
• Brain and/or Heart Abnormalities
• Neurotransmitter deficiencies
• Distorted familial breathing patterns
• Lack of surfactant

Ways to Prevent SIDS

• Have the baby sleep on his/her back
• Keep the crib as bare as possible
• Don’t overheat
• Have them sleep in your room
• Breast-feed the baby
• Use a pacifier
• Immunize the baby

Hyperbilirubinemia

• Elevated Bilirubin Levels due to breakdown of red blood cells
• Liver dysfunction
• ABO incompatibility

Causes of Hyperbilirubinemia + Jaundice are

• Physiologic Jaundice
• Breast Milk
• Hemolysis
• and Inadequate Liver Function

Symptoms of Hyperbilirubinemia

• Yellow tint to skin and eyes
• Poor feeding and/or lethargy

Diagnosis of Hyperbilirubinemia

• Jaundice appearing within he first 24 hours
• Elevated hematocrit indicates hemolysis

Treatment for Hyperbilirubinemia

• Phototherapy
• Fiberoptic Blanket
• Exchange Transfusion
• Hydration

Twin to Twin Transfusion

• Occurs in in identical twins sharing the same placenta
• An arteriovenous shunt causes the twin to take more blood from the donor twin

Treatment for Twin to Twin Transfusion

• Expectant management
• Amnioreduction
• Fetoscopic laser photocoagulation
• Delivery

Retinopathy of Prematurity

• An acquired ocular disease that leads to total or partial blidness

Scleral Buckling

• Treatment focuses on peripheral retina to preserve central retina
• Surgeries that may be performed are laser and/or injection

Spina Bifida

• Defects in the neural tube that fails to close completely

Classifications

• Occulta
• Meningocele
• Myelomeningocele

Diagnosis

• Amniocentesis
• Ultrasounds

Treatment

• Surgical
• Infection Prevention
• Skin Integrity