High-Risk Infant PDF

High Risk Infant  Definition of High Risk Infant A newborn, regardless gestational age or birth weight, who has a greater-than-average chance of morbidity or mortality. The high risk period envolves human growth and development from the time of viability (28 weeks of gestation) up to 2...

High Risk Infant  Definition of High Risk Infant A newborn, regardless gestational age or birth weight, who has a greater-than-average chance of morbidity or mortality. The high risk period envolves human growth and development from the time of viability (28 weeks of gestation) up to 28 days following birth.  Classification of high-risk newborns According to: 1.Birth Weight 2.Intra-uterine growth 3.Gestational age 4. Viability  According to Birth Weight Low-birth-weight (LBW) infant : an infant whose birth weight is 2500 g or less , regardless of gestational age. Very low-birth-weight (VLBW) infant :an infant whose birth weight is 1500g or less , regardless of gestational age. Extremely-low-birth-weight (ELBW) infant: an infant whose birth-weight is 1000g less , regardless of gestational age.  2. Intra-uterine Growth Appropriate-for-gestational-age (AGA): an infant whose birth-weight is falls between the 10th and 90th percentiles on intrauterine growth curves. Small-for-gestational age (SGA): an infant whose birth weight falls below the 10th percentile on intrauterine growth curves due to intrauterine growth retardation – IUGR. Large-for-gestational-age (LGA): an infant whose birth weight falls above the 90th percentile on intrauterine growth curves.  3. Gestational age: Premature (preterm) infant: an infant born before completion of 37 weeks of gestation, regardless of birth weight. (< 37 WGA) Full-term infant: an infant born between the beginning of the 37 weeks and the completion of the 42 weeks of gestation, regardless of birth weight. (37 – 42 WGA) Postmature (post-term) infant: an infant born after 42 weeks of gestational age ,regardless of birth weight. (>42 WGA)  4. Viability 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 28 days of life; early neonatal death occurs in the first week of life ; late neonatal death occurs at 7-28 days. Perinatal mortality: total number of fetal and early neonatal deaths per 1000 live births  Factors that contribute to have a High- risk Neonate High risk pregnancies: medical disease of the mother as DM, eclampsia Complications of labour: PROM, obdtructed labour, hypoxia. Neonatal factors: prematurity, LBW, congenital anomalies, twins  Consequences Premature birth Low birth weight infants infants suffering from: Hypothermia, Hypoglycemia, Infant of Diabetic Mother (IDM), Neonatal Sepsis, Hypoxic Ischemic Encephalopathy, Hyperbilirubinemia, and Respiratory Distress Syndrome (RDS).  HYPOTHERMIA It is a condition characterized by lowering of body temperature than 36°C. Types of Hypothermia according to Severity: (1) Mild Hypothermia: When the infant’s body temperature is less than 36°C. (2) Moderate Hypothermia: When the infant’s body temperature is less than 35.5°C. (3) Severe Hypothermia: When the infant’s body temperature is less than 35°C.  Causes Primary Hypothermia: related to the birth process The normal term infant when delivered into a warm environment may drop its temperature by 1 – 2°C shortly after birth and may not achieve a normal stable body temperature until the age of 4 – 8 hours. In low birth weight infants, this decrease in body temperature may be much greater and more rapid unless special precautions (careful dryness) are taken immediately after birth. Secondary Hypothermia: causes other than those related to the birth process) 1. Acute infection (Septicemia). 2. Blood loss (hemorrhage) 3. metabolic (hypoglycemia)  Clinical Picture 1- Low body temperature 2- Cyanosis, cold skin 3- Apathy, refusal of or poor feeding 4- Shallow respiration, apnea. 5- Decrease activity, e.g.: weak crying, immobility, 6- Hypotension & Oliguria. 7- Metabolic disturbances: Hypoglycemia, acidosis. 8- Hematological manifestations: massive pulmonary hemorrhage and disseminated intra- vascular coagulation.  HYPOGLYCEMIA Neonatal hypoglycemia is defined as a serum glucose value of < 40 mg/dl. For the preterm infant, a value of < 30 mg/dl is considered abnormal. Untreated hypoglycemia can result in permanent neurological damage or death.  Neonates at risk for developing hypoglycemia: 1.Maternal malnutrition 2.Small forgestational age(SGA),or large for gestational age (LGA) 3.Infants of diabetic mothers(IDM) 4.Abnormal placentae e.g. placenta previa 5. Maternal toxemia e.g. pre-eclampsia and eclampsia 6. Induction of labour & pre-term birth 7. Very ill or stressed neonates with reduced matabolic reserve e.g. asphyxia, hypothermia, infection, respiratory distress syndrome, or cardiac failure  Clinical manifestations may be asymptomatic or: 1. Hypotonia. 2- Feeding poorly after feeding well. 3- Tremors 4- Apnea, Cyanotic spells. 5- Lethargy. 6- Seizures.  Infant of diabetic mother Maternal hyperglycemia (due to maternal diabetes mellitus) Fetal hyperglycemia Fetal hyperinsulinemia. At birth, the separation of the placenta interrupts the glucose infusion to the baby leaving high level insulin without glucose and leading to hypoglycemia in the neonate.  NEONATAL SEPSIS The newborn infant is very susceptible to acquire infection, whether bacterial, viral or fungal. Bacterial sepsis and meningitis continue to be major causes of morbidity and mortality in the newborn. The mortality rate due to sepsis ranges from 20% to as high as 80% among neonates. Surviving infants can have significant neurologic squeal because of CNS involvement.  Neonatal sepsis is a disease of neonates (who are younger than one month) in which they are clinically ill and have a positive blood culture. In most cases, the condition is not localized and called Neonatal Septicemia In other cases, in addition to its systemic nature of the infection could be localized to give for example: Pneumonia, Meningitis, Hepatitis, Septic arthritis or Osteomyelitis, Urinary Tract Infection.  Risk factors Maternal risk factors: prolonged / premature rupture of membranes (chorioamnionitis) prolonged instrumental delivery maternal fever maternal urinary tract infection. Neonatal risk factors: Prematurity (less immunologic ability to resist infection + more liable to penetrate their defensive barriers) male sex need for resuscitation at birth congenital defects Bacteria can reach the fetus or newborn and cause infection in one of the following ways: 1. Through the maternal blood through placenta (Transplacental) 2.Through the vagina or cervix entering to the uterus (During labour) 3.Contact with bacteria in its environment after birth (Nosocomial)  Hypoxic Ischemic Encephalopathy It is an important cause of permanent damage to the brain cells. Hypoxia: Arterial oxygen concentration is less than normal. Ischemia: Blood flow to the cells or the organs which is not sufficient to maintain their metabolic functions. Etiology: Perinatal causes (due to maternal, placental causes), natal or post natal causes. Diagnostic criteria: 1.Fetal acidosis: cord blood pH is less than 7.1. 1-Apperance (color) 2-Pulse 3-Grimace response (reflex) 4- 2.Five-minutes APGAR score less than 3. Activity (muscle tone) 5-Respiration 3.Multi-organ affection (acute tubular necrosis, cardiomyopathy...etc.). 4.Picture of encephalopathy: altered sensorium, altered tone, seizures...etc. may be mild (grade I) or moderate (grade II: with seizures) or severe (grade III) Prognosis: 15%-20% die in neonatal period. 30% of the survivors are left with permanent neuro- developmental abnormalities. 55% survive normally  HYPERBILIRUBINEMIA HYPERBILIRUBINEMIA is an elevation in the neonatal serum bilirubin ; characterized by JAUNDICE, which is defined as yellowish discoloration of skin and mucous membranes , diagnosed if the total serum bilirubin is ≥ 5 mg/dl. Bilirubin is a yellow pigment that is produced during the normal breakdown of red blood cells. The liver processes bilirubin so it can be excreted from the body. When the levels of bilirubin rise, it can lead to jaundice, which is the yellowing of the skin and eyes.  Possible causes of hyperbilirubinemia in the newly born infants Over production of bilirubin. Under excretion of bilirubin. Combined over production and under excretion. Physiological jaundice (immaturity of liver enzymes).  Complications The most common complication of hyperbilirubinemia is Kernicterus (Bilirubin Encephalopathy), which usually occurs when the unconjugated serum bilirubin level exceeds than 20 mg/dl. In small, sick preterm infants, even a bilirubin level in a low range may cause Kernicterus.  Clinical Presentation of Bilirubin Encephalopathy Kernicterus progresses through 4 stages: Stage I: Poor Moro reflex, poor feeding, vomiting, high- pitched cry, decreased tone and lethargy....(NICU) Stage II: Spasticity, seizures, fever. Neonatal mortality is high at this stage (80%)....(NICU) Stage III: A symptomatic (Spasticity decreases and all remaining clinical signs and symptoms may disappear) or floppiness and developmental delay....(Home) Stage IV: Appears after the neonatal period. Long-term sequelae can include: choreo- athetosis, dystonia, spasticity quadriplegia, deafness and mental retardation ( 20%) (Home) stage 2: 1-Irritability: Increased fussiness and irritability. 2-Altered Muscle Tone: May show either increased tone (hypertonia) or continued hypotonia. 3-Arching of the Back: Hyperextension of the back (opisthotonos) may occur. 4-Seizures: Some infants may begin to experience seizures.  Respiratory distress syndrome (RDS) = Hyaline membrane disease (HMD) Respiratory distress syndrome is due to low level or absence of surfactant system Risk factors (High risk group): Prematurity and low birth weight Patho-physiology: It is a primarily a disease of pre-terms. During intrauterine life, alveoli are filled with fetal lung fluid. At birth, the baby cries to create a negative pressure to open the alveoli. Then the alveoli do not collapse during expiration because of a lipoprotein material called “surfactant” secreted by type II alveolar cells. Its action is to decrease the surface tension inside the alveoli, thus preventing their collapse during expiration. If surfactant is deficient, every inspiration a higher negative pressure is needed to to inflate the alveoli leading to rapid fatigue and respiratory distress.  Clinical Presentation Grade I: (Mild distress): Rapid respiratory rate (tachypnea >60 breaths per minute) + nasal flaring (alae nasai). Grade II: (Moderate distress): GI + intercostals and substernal retractions. Grade III: (Severe distress): GI + GII + expiratory grunting. Grade IV: (Advanced distress): GI + GII + GIII + central cyanosis and disturbed consciousness.  MANAGEMENT OF HIGH-RISK INFANT Physical assessment Thermoregulation Management of consequences of cold stress- hypoxia, metabolic acidosis, hypoglycemia Glucose & calcium 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 in all babies gavage feeding-