Preterm Newborn Assessment and Care

Preterm Newborn

• Born before 37 weeks AOG but greater than 20 weeks AOG.
• The primary concern is the immaturity of all body systems.

Assessment

• Respirations are often irregular with periods of apnea.
• Body temperature is below normal axillary.
• Exhibits poor suckling and swallow reflexes.
• Diminished bowel sounds can be noted.
• Urinary output may be increased or decreased.
• Thin extremities with minimal creasing on soles and palms
• Lanugo is present in woolly patches.
• Skin is thin, with visible blood vessels and minimal subcutaneous fat pads
• Skin may appear jaundiced.
• Testes are undescended in boys.
• Labia majora are narrow in girls.

Nursing Interventions

• Monitor vital signs every 2 to 4 hours.
• Maintain airway and cardiopulmonary functions.
• Administer oxygen and humidification as prescribed.
• Monitor I&O and electrolyte balance.
• Monitor daily weight.
• Maintain the NB in a warming device.
• Avoid exposure to infections due to being immunocompromised.
• Practice Kangaroo Mother Care (KMC)
• KMC, where the newborn is carried, usually by the mother, with skin-to-skin contact
• KMC is intended for the HCP responsible for the care of LBW and preterm infants.

Postterm Newborn

• An infant born after 42 weeks AOG

Assessment

• Hypoglycemia may be present.
• Parchment-like skin (dry / cracked) without lanugo.
• Long fingernails might be seen.
• Profuse scalp hair.
• Long and thin body.
• Wasting of fat muscle in extremities
• Meconium staining may be present on nails and umbilical cord.
  • Yellow or green in color, because of fetal distress

Nursing Interventions

• Provide normal newborn care.
• Monitor for hypoglycemia:
  • Due to abrupt changes in nutrient passage from the mother's placenta.
• Maintain NB’s temperature.
• Monitor for meconium aspiration.

Small for Gestational Age (SGA)

• NB plotted below the 10th percentile on the intrauterine growth curve
• Normal : 5.5lbs-8.8 lbs..

Low Birth Weight (LBW)

• Less than 2,500 grams (< 2.5kg)

Very Low Birth Weight (VLBW)

• Less than 1,500 grams (< 1.5kg)

Extremely Low Birth Weight (ELBW)

• Less than 1,000 grams (< 1kg)

Large for Gestational Age (LGA)

• NB plotted at or above the 90th percentile on the intrauterine growth curve
• 19.2 lbs

Note

• Mothers with diabetes usually result in having LGA babies.

Assessment

• Birth trauma or injury (shoulder dystocia) can occur.
• Respiratory distress may be present.
• Hypoglycemia should be assessed.

Nursing Interventions

• Monitor vital signs and for respiratory distress.
• Monitor for hypoglycemia.
• Initiate early feedings every 2-3 hours.
• Monitor for infection and initiate measures to prevent sepsis.

Respiratory Distress Syndrome (RDS) (Hyaline Membrane)

• Caused by immaturity and inability of the lungs to produce surfactants
  • Results in hypoxia and acidosis
  • Common in premature babies
• Hypoxia: Low oxygen in the tissues.
• Acidosis: Acid buildup

Assessment

• Tachypnea (> 60cpm)
• Nasal flaring indicates increased respiratory effort
• Expiratory grunting may be noted
• Retractions
• Seesaw respirations
• Decreased breath sounds
• Apnea
• Pallor and cyanosis
• Hypothermia
• Poor muscle tone

Infant Distress

• Grunting signals may be a warning sign of infant distress

Nursing Interventions

• Monitor color, RR, and degree of effort in breathing

Jaundice

• Excessive accumulation of bilirubin in the blood, a byproduct of RBC breakdown
  • Characterized by jaundice (icterus)
  • Yellow discoloration of the skin and organs
• Usually benign and common in NB.
• May result from increased conjugated or unconjugated form of bilirubin.
  • Most commonly seen in NB
• Highly toxic to neurons

Monitor

• Evaluate for early onset
• May indicate hemolysis RBC
• Should be reported to the physician

Pathologic Jaundice

• Usually related to hemolytic disease of the newborn (HDN - Rh / ABO incompatibility), sepsis, or one of the maternally derived diseases such as DM or infections
• Severe jaundice

Physiologic Jaundice

• Not associated with any pathology.
• Appears after the first 24 hours in full term or first 48 hours in preterm.
• Peak at 5th DOL and is transient/benign.
• Other factors include cephalhematoma, large amount of bruising, or infection.
• Evaluation is indicated when serum levels are over 12mg/dl in the term NB. At any serum bilirubin level, the appearance of jaundice during the first DOL indicates a pathological process.

Complications

• Early varying degrees of acute symptoms of bilirubin toxicity resulting from the deposition of unconjugated bilirubin in brain cells.
• Kernicterus:
  • Also known as bilirubin-induced neurologic dysfunction.
  • Describes the yellow staining of the brain cells and brain cell necrosis
    • Results in chronic, permanent changes to the brain secondary to bilirubin deposition in the brain.

Types of Jaundice

• Immature hepatic formation plus increased bilirubin load from RBC hemolysis
• Onset : After 24 hours (proterm infants, prolonged)
• Peak : 2nd to 5th day

Breastfeeding-associated (Early Onset)

• Decreased milk intake related to fewer calories consumed by infant before mother's milk is well-established; enterohepatic shunting; less frequent stooling
• Onset: 3rd to 4th day

Breastmilk Jaundice (late Onset)

• Possible factors in breast milk that prevent bilirubin conjugation; less frequent stooling
• Onset : 4th

Hemolytic disease

• Blood antigen incompatibility causing hemolysis of large numbers of RBCs; functional inability of the liver to conjugate and excrete excess bilirubin from hemolysis
• During first 24hrs (levels increase more than or equal to 5mg/dl/day)

Goal

• Excrete bilirubin

Other Jaundice parameters

• Timing and appearance of jaundice
• Gestational age
• Age in days since birth (DOL)
• Family history (ex: maternal Rh factor)
• Evidence of hemolysis
• Feeding method
• Infant's physiologic status
• Progression of serial serum bilirubin

Nursing interventions

• The goal of therapy is aimed at preventing kernicterus, which results in permanent neurological damage resulting from deposition of bilirubin in the brain cells or any blood incompatibilities
• Monitor the presence of jaundice
  • Assess skin and sclera for jaundice
• Examine the NB's skin color in natural light
  • Note that jaundice starts at the head first then spreads to the chest, abdomen, arms and legs, and hands and feet which are last
• Facilitate early, frequent feeding to hasten passage of meconium and encourage excretion of bilirubin
• Report to the physician any signs of jaundice in first 24 hours and any abnormal signs or symptoms
• Prepare for phototherapy
  • Expose as much skin as possible
    • Cover the genital area to prevent soiling
    • Cover the NB's eyes with eye shield or patches to prevent exposure to the light
    • Remove the shield or patches at least once per shift (during feeding time) to inspect the eyes for infection or irritation and to allow for eye contact and bonding with parents
  • Measure the lamp energy output to ensure efficacy of the treatment (done with photometer)
  • Monitor temperature closely
• Keep NB well hydrated.
  • Increase fluid intake to maintain blood volume and prevent dehydration
• Monitor the NB’s skin color with the fluorescent light turned off every 4 to 8 hours
• Consists of exposing the infant’s skin to an appropriate light source to promote bilirubin excretion to photoisomerization
  • Which alters the structure of bilirubin to a soluble form (lumirubin)
• Enhances the excretion of bilirubin but does not inhibit its production

Conditions caused by the exposure to light

• Bronze baby syndrome:
  • Serum, urine, and the skin turn grayish brown several hours after the infant is placed under the light.
• Caused by retention of a bilirubin breakdown product of phototherapy, possibly copper porphyrin

Side effects to light exposure

• Loose, green stools
• Skin rashes
• Increased metabolic rate
• Hyperthermia – due to prolonged exposure
• Dehydration

Exchange Transfusion

• Indicated for severe hyperbilirubinemia
• Small amounts of blood are withdrawn and replaced through an umbilical vein catheter to remove partially hemolyzed antibody-coated RBCs and replace them with uncoated donor RBCs
• Specific indications
  • Serum bilirubin > 20mg/dl at 24 to 48hrs -> 5mg/dl at >48 hours
  • Failure of phototherapy to result in a 1-2 mg/dl decrease within 4-6 hours of initiation

Sepsis

• One of the reasons of NB mortality
• Generalized infection resulting from the presence of bacteria in the blood
  • Such as Group B Streptococcal infection
• Preterm neonates are at a higher risk for sepsis or infection than term neonates due to
  • Deficient immune system, mainly due to decreased IgG antibodies and incompetent opsonization and complement activation
  • Comprised innate immune system, caused primarily by the immature epithelial barrier
  • Increased need for invasive devices (vascular access, endotracheal tube, feeding tubes, urinary tract catheters) due to associated severe illnesses
• Neonatal sepsis may be prenatally acquired, during labor, early sepsis (1 to 3 days of age), or late sepsis (1 to 3 weeks of age)

Early-onset Sepsis (EOS)

• Caused by transmission of pathogens from the female genitourinary system to the NB or fetus
• These pathogens can descend to the vagina, cervix, and uterus, and can infect the amniotic fluid
• Neonates can also be infected in utero or during delivery as they pass through the vaginal canal
• Maternal factors that increase risk of neonatal sepsis include GBS colonization, chorioamnionitis, delivery before 37 weeks, and prolonged rupture of membranes greater than 48 hours

Late-onset Sepsis (LOS)

• Occurs via the transmission of pathogens from the surrounding environment after delivery
• May also be caused by a late manifestation of vertically transmitted infection
• Infants requiring IV catheter insertion, or other invasive procedures that disrupt the mucosa, are at an increased risk for developing LOS

Diagnostic Procedures

• CBC
• Differential smear
• Blood culture
• Urine culture
• Lumbar puncture if clinically feasible

GBS Screening

• A vaginal screening (for mothers) done to examine if there is presence of bacteria

Lumbar Puncture

• Done by getting a sample of the CSF of an individual
• Can also diagnose leukemia and meningitis

Assessment

• Pallor
• Tachypnea, tachycardia
• Poor feeding
• Abnormal distention
• Temperature instability

Nursing interventions

• Assess for periods of apnea or irregular respirations
  • Stimulate by gently rubbing the chest or foot if apnea is present
• Administer oxygen as prescribed
• Monitor VS, assess for fever
• Maintain warmth in a radiant warmer
• Provide isolation as necessary
• Monitor I&O and obtain daily weight
• Monitor for diarrhea
• Assess feeding and sucking reflex, which may be poor
• Assess for jaundice
• Assess for irritability and lethargy
• Prepare for blood cultures and administer antibiotics as prescribed
• Observe carefully for toxicity due to immature liver and kidneys of the NB

Rh Incompatibility

• Rh positive = presence of antigen
• Rh negative = absence of antigen
• Also known as hemolytic disease of the newborn (HDN)
• Destruction of RBCs that results from an antigen-antibody reaction
• Characterized by hemolytic anemia or hyperbilirubinemia
• Because the condition begins in utero, the fetus attempts to compensate for the progressive hemolysis by accelerating the rate of erythropoiesis

Assessment

• Anemia
• Jaundice that develops rapidly after birth and before 24 hours
• Edema

Nursing interventions

• Administer Rho(D) Immune Globulin to the mother during the first 72 hours after birth if the Rh-negative mother delivers an Rh-positive fetus but remains unsensitized
• Assist with exchange transfusion after birth or intrauterine transfusion as prescribed
• The NB’s blood is replaced with Rh-negative blood to stop the destruction of the NB’s RBCs, the Rh-negative blood is replaced with the NB’s own blood regularly
• Provide support to the parents
• Rho (D) Immune Globulin
• Prevention of anti-Rho (D) antibody formation is most successful if the medication is administered twice at 28 weeks AOG and again within 72 hours after delivery
• Rho (D) Immune Globulin also should be administered within 72 hours through IM after potential or actual exposure to Rh-positive blood and must be given with each subsequent exposure or potential exposure to Rh positive blood

Fetal Alcohol Spectrum Disorders (FASDs)

• A group of conditions caused by maternal alcohol use during pregnancy
• Result of teratogens
• Cause cognitive and physical delays
• The most severe out of the FASDs
• Other disorders included are alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBDs)

Facial changes

• Short palpebral fissures
• Hypoplastic philtrum
• Short, upturned nose
• Flat midface
• Thin upper lip
• Low nasal bridge
• Abnormal palmar creases
• Respiratory distress (apnea, cyanosis)
• Congenital heart disorders
• Irritability and hypersensitivity to stimuli
• Tremors
• Poor feeding
• Seizures

Nursing Interventions

• Monitor for respiratory distress
• Position the NB on the side to facilitate drainage of secretions; initiate seizure precautions’
• Keep resuscitation equipment at the bedside
• Monitor for hypoglycemia
• Assess sick and swallow reflex
• Administer small feedings and burp well
• Suction as necessary
• Monitor I&O
• Monitor weight and head circumference
• Decrease environmental stimuli as imitable

Newborn of a Mother with Human Immunodeficiency Virus (HIV)

• NB born to HIV positive mothers may test positive as the mother’s antibodies may persist in the NB for 18 months after birth
• All NB born to HIV positive mothers acquire maternal antibody to HIV infection, but not all acquire the infection
• The NB may be asymptomatic for the first several months to years of life

Transmission

• Across placental barrier
• During labor and birth
• Sexual intercourse
• Blood transfusion
• Breastmilk

Note

• The use of antiretroviral medication, the reduction of NB exposure to maternal blood and body fluids, and the early identification of HIV in pregnancy reduce the risk of transmission of NB
• Mothers who are HIV positive cannot breastfeed their babies as this illness can be transmitted via breastmilk
• However, they can do so if and only if, they are taking antiretroviral drugs

Assessment

• Possibly no outward signs at birth
• Signs of immunodeficiency
• Hepatomegaly (enlarged liver)
• Splenomegaly (enlarged spleen)
• Lymphadenopathy
• Impaired growth and development
  • Persistent generalized lymphadenopathy is defined as the development of enlarged lymph nodes in two or more of the following sites: neck, axilla, and groin

Serological Tests (or antibody)

• Tests (also called rapid tests) detect antibodies made by immune cells in response to the virus
• Do not detect the virus itself
• An HIV-infected mother produces antibodies in her blood
  • These antibodies from the mother can get into the baby during delivery and may stay in the child’s month until the age of 18 moths
  • This means that a positive antibody test in children under the age 18 months is not reliable and does not confirm that the child is infected
• Serological / antibody tests are used to confirm HIV infection in children who are more than 18 months

Virological Tests

• Directly detect HIV in the blood
• Can detect HIV infection before the child is 18 months old

Nursing Interventions

• Clean the NB’s skin carefully before any invasive procedure
• Circumcisions:
  • Are not done on NB with HIV-positive mothers until the NB’s status is determined
• All HIV-exposed NB should be treated with medication to prevent infection by Pneumocystis jiroveci
• Antiretroviral medications may be administered as prescribed for the first 6 weeks of life or longer
• Monitor for early signs of immunodeficiency, such as written on the assessment
• NB at risk for HIV infection should be seen by the PHCP at birth, and at 1 week, 2 weeks, 1 month, and 2 months of age
• Inform the mother that HIV culture is recommended at 1 month and after 4 months of age
• Immunizations with live vaccines such as measles, mumps, rubella, and varicella
  • Should not be done, until the NB’s status is confirmed
  • If infected, live vaccine will not be given