High-Risk Newborns: Classification and Care

• High-risk newborns have a greater-than-average chance of morbidity or mortality, regardless of gestational age or birth weight, due to conditions beyond normal birth events.
• Anticipating the need for specialized care increases the probability of a successful outcome for high-risk newborns.
• Prompt assessment and intervention in perinatal emergencies can significantly impact outcomes.

Classification of High-Risk Infants

• High-risk infants are often classified based on size, gestational age, and mortality factors.
• Common problems related to physiologic status include maturity-related issues and chemical disturbances like hypoglycemia or hypocalcemia.
• Immature organs and systems can lead to hyperbilirubinemia, respiratory distress, and hypothermia.

Classification According to Size

• Low-birth-weight (LBW) infants weigh less than 2500 g (5.5 lb), irrespective of gestational age.
• Very-low-birth-weight (VLBW) infants weigh less than 1500 g (3.3 lb).
• Extremely low-birth-weight (ELBW) infants weigh less than 1000 g (2.2 lb).
• Appropriate-for-gestational-age (AGA) infants have a weight between the 10th and 90th percentiles on intrauterine growth curves.
• Small-for-date (SFD) or small-for-gestational-age (SGA) infants have a birth weight below the 10th percentile, indicating slowed intrauterine growth.
• Intrauterine growth restriction (IUGR) describes infants with restricted intrauterine growth.
• Large-for-gestational-age (LGA) infants have a birth weight above the 90th percentile on intrauterine growth charts.

Classification According to Gestational Age

• Preterm (premature) infants are born before 37 weeks of gestation.
• Full-term infants are born between 38 and 42 weeks of gestation.
• Late-preterm infants are born between 34 0/7 and 36 6/7 weeks of gestation.
• Post-term (postmature) infants are born after 42 weeks of gestational age.

Classification According to Mortality

• Live birth indicates a neonate exhibiting any heartbeat, breath, or voluntary movement, regardless of gestational age.
• Fetal death is the death of a fetus after 20 weeks of gestation and before delivery, with no signs of life after birth.
• Neonatal death occurs in the first 27 days of life; early neonatal death occurs in the first week, and late neonatal death occurs from 7 to 27 days.
• Perinatal mortality is the total number of fetal and early neonatal deaths per 1000 live births.
• Postnatal death occurs from 28 days to 1 year after birth.

Nursing Care of High-Risk Newborns: Assessment

• Focus is on evaluating cardiopulmonary and neurologic functions.
• Assessment includes Apgar score assignment and evaluation for congenital anomalies or signs of distress.
• Assessments are based on the infant’s acuity, with critical infants requiring close observation of respiratory function, including continuous pulse oximetry, electrolytes, and blood gases.

Monitoring Physiologic Data

• Neonates under intensive observation are typically placed in a controlled thermal environment and monitored for heart rate, respiratory activity, and temperature.
• Blood pressure is monitored routinely using internal or external methods, with arterial catheters carrying inherent risks.
• Accurate intake and output records are essential, with urine output measured using plastic collection bags or by weighing diapers.

Laboratory Examinations

• Laboratory tests like blood glucose, bilirubin, electrolytes, calcium, hematocrit, and blood gases are vital for monitoring the sick newborn’s progress.
• Samples can be obtained through heel stick, venipuncture, arterial puncture, or indwelling catheters.
• The frequency of vital signs monitoring depends on the infant’s acuity level and response to handling.
• Safety measures, including reliable devices and trained operators, are crucial to minimize electrical biohazards.
• Parents should be educated on safety measures to prevent infant abduction.

Respiratory Support

• Establishing and maintaining respiration is the primary objective.
• Supplemental oxygen and assisted ventilation may be necessary, along with proper positioning to ensure an open airway and maximize oxygenation.
• Oxygen therapy is provided based on the infant’s requirements and illness.

Thermoregulation: Pathophysiology

• Immature neonates produce heat mainly through increasing metabolic rate, lacking a shivering response.
• Non-shivering thermogenesis is the major source of increased heat production during cold stress.
• Cold stress can lead to hypoxia, metabolic acidosis, and hypoglycemia due to increased oxygen and calorie consumption.
• Prevention of heat loss is essential for survival, and maintaining a neutral thermal environment is a challenging aspect of neonatal intensive nursing care.
• Heat production is affected by cardiovascular, neurologic, and metabolic systems.

Maintaining Thermoneutrality

• At-risk newborns are placed in a heated environment immediately after birth to prevent cold stress.
• Methods include using an incubator, radiant warming panel, or open bassinet with cotton blankets.
• Conductive heat loss can be reduced by warming items that come into direct contact with the infant.

Protection From Infection

• Frequent hand washing, preventing personnel with infectious disorders from entering the unit, and using Standard Precautions are essential.
• Isolation of infants with communicable illnesses is necessary.

Hydration

• Infusion rates are carefully regulated to prevent tissue damage, fluid overload, or dehydration.
• Over-infusion can lead to pulmonary edema, congestive heart failure, patent ductus arteriosus (PDA), and intraventricular hemorrhage (IVH).
• Dehydration may cause electrolyte disturbances with potential central nervous system (CNS) effects.
• Adequate hydration is crucial for preterm infants due to their higher extracellular water content and limited ability to concentrate urine.
• Common routes of fluid infusion include peripheral, peripherally inserted central venous, surgically inserted central venous or arterial, and umbilical catheterization.

Nutrition

• The American Academy of Pediatrics recommends an energy intake of 105 to 130 kcal/kg/day for most preterm infants.
• Nutrition can be provided parenterally or enterally.
• Daily monitoring of weight, electrolytes, renal function, calcium, and hydration status is necessary.
• Early introduction of small amounts of oral colostrum priming (OCP) can stimulate the GI tract, prevent mucosal atrophy, reduce the risk of sepsis, and shorten hospitalization.
• Early feeding reduces the incidence of hypoglycemia, dehydration, and hyperbilirubinemia.
• Feeding success is evaluated by the infant's energy during feeding, coordination of sucking and swallowing, stable vital signs, normal muscle tone, and completion of feeding in 20 to 25 minutes.
• Feeding tolerance is evaluated by a soft abdomen, absence of distention, minimum gastric residual, presence of bowel sounds, and usual stools.

Skin Care

• Preterm infants have immature, sensitive skin.
• Skin products like alcohol or povidone-iodine should be used cautiously and rinsed off with water.
• Scissors must be used carefully to avoid injury.
• Bony prominences should be protected with clear dressings.