Vulnerability of Infants and Early Discharge PDF

Vulnerability All infants are vulnerable, even those born at 38--42 weeks following a healthy pregnancy and an uneventful birth. Transition to extra-uterine life is challenging for all infants. Tremendous adaptation is required. Circulatory pathways must change from fetal to newborn patterns. The l...

Vulnerability All infants are vulnerable, even those born at 38--42 weeks following a healthy pregnancy and an uneventful birth. Transition to extra-uterine life is challenging for all infants. Tremendous adaptation is required. Circulatory pathways must change from fetal to newborn patterns. The lungs must inflate and assume responsibility for gas exchange. Thermal stability outside the warm intrauterine environment must be achieved. Glucose homeostasis, without access to maternal glucose supply, must be accomplished. Foreign and potentially pathogenic microorganisms must be dealt with. Noise, light, touch, and handling are new sensations, and stooling and voiding patterns must be established. Although term infants are more equipped than preterm infants to cope with adaptation to life apart from maternal supports, their organ systems remain vulnerable. These systems function within a narrow range of optimal conditions. Too much or too little glucose and/or fluid can result in hydration and/or glucose complications. Too much or too little environmental heat can result in temperature instability. Microorganisms can overwhelm the immune system, producing sepsis. Retained lung fluid can produce respiratory distress and the ductus arteriosus can remain patent. Early Discharge The term "early discharge" has been used in recent years to denote a change toward a shorter length of hospital stay for mothers and infants. For most full-term, healthy infants, a home environment is the most appropriate. However, in this module, we are suggesting that early discharge may also impose risks. We look at why that is and at the source of those risks. We explore these questions through the case study of James. James is a "normal" full-term newborn. Although he is as well prepared for extra-uterine life as he can be, he remains vulnerable. Early discharge from hospital further increases his vulnerability. Through the case, we will explore James' vulnerability in relation to breastfeeding, jaundice, and dehydration, and their effects on infant well-being. These complications are not uncommon for infants like James. In addition, we will also explore the family issues of postpartum depression and sibling adjustment to the birth of an infant. One of the complications of early discharge is that those mothers and families who experience problems at home are vulnerable because the problems may go unrecognized and therefore untreated. All of the risks commonly associated with early maternity discharge are, or will soon be, evident in Claire's case. Breastfeeding issues, jaundice, postpartum depression and sibling adjustment will all be addressed within the next few sections. It should be noted that the pathophysiological processes being addressed are not unique to James' case, nor are they unique to post-discharge situations. All infants are at risk for feeding issues, jaundice and dehydration. Preterm infants are at a higher risk because of anatomical and physiological immaturity. All mothers are at risk for postpartum depression, and sibling adjustment is always a concern. Before we look at risks associated with early maternity discharge, we examine one of the leading causes of infant death in Canada and a key source of infant vulnerability: critical congenital heart disease (CCHD). Critical Congenital Heart Disease (CCHD) What is CCHD? Congenital heart disease (CHD) is the most common congenital malformation, with a prevalence of 12/1,000 live births in Canada. Approximately one-quarter of these newborns have CCHD, defined as more severe and often duct-dependent lesions that require intervention early in life for optimal outcome (Narvey, Wong & Fournier, 2017). The primary targets for CCHD screening are hypoplastic left heart syndrome, pulmonary atresia with intact ventricular septum, transposition of the great arteries, truncus arteriosus, tricuspid atresia, tetralogy of Fallot, and total anomalous pulmonary venous return. Screening can sometimes identify other forms of CHD (AAP, 2018). Why do we perform CCHD pulse oximetry screening? CHD is the leading cause of infant death in Canada (Wong et al., 2017). Approximately 25%--35% of congenital heart defects are diagnosed after discharge from the hospital (Narvey, Wong and Fournier, 2017). Early diagnosis is crucial for decreasing morbidity, mortality and disability related to delayed diagnosis of CHD. To decrease the rate of undiagnosed CCHD, nurses are now required to screen all infants prior to discharge from the hospital, or a midwife in the community will screen them after a home birth. How do we perform CCHD pulse oximetry screening? The Canadian Paediatric Society (2017) recommends routine pulse oximetry screening for all newborns in Canada to increase the detection of CHDs. Pulse oximetry is safe, non-invasive, easy to perform and widely available. Ideally, the testing should be done between 24 and 36 hours of age, as testing prior to 24 hours significantly increases the rate of false positives due to transition from fetal circulation. The test includes pulse oximetry measurement of preductal (right hand) and postductal (either foot) oxygen saturations. The baby passes the screening if the oxygen saturation is 95% or greater in the right hand and foot and the difference is three percentage points or less between the right hand and foot. The screen is immediately failed if the oxygen saturation is less than 90% in the right hand and foot. If the oxygen saturation is greater than 90% and less than 95% in the right hand and foot, or there is more than a three-percent difference between the right hand and foot, then the screen must be repeated in one hour according to the same process as above. Rarely, some babies will require three screens (that is, the initial and two repeat screens, all separated by one hour). A baby whose oxygen saturation is from 90% to less than 95% in either the right hand and foot, or who has more than a three-percent difference between the right hand and foot after the third screen, will be considered to have failed screening (Wong et al., 2017). CCHD screening algorithm (Wong et al., 2017) (Wong et al., 2017) What happens if an infant fails the screening? After a failed screen, the infant should be examined by the most responsible health care provider to make sure the baby is hemodynamically stable, and the infant should also be evaluated for hypoxemia. Depending on the status of the baby, this could involve evaluating for sepsis or pneumonia. Any signs or symptoms of congenital heart disease should prompt rapid evaluation, including potential transfer to a centre with advanced care capabilities (AAP, 2018). If a cardiac diagnosis cannot be confidently excluded, a cardiologist or neonatologist should be consulted and an echocardiogram should be performed. Newborns should not be discharged home until the underlying reason for hypoxemia has been identified or the hypoxemia has resolved. These babies will often appear normal and have no clinical findings other than low oxygen saturation. This may be the only indication that the infant has a serious cardiac defect (AAP, 2018). What about premature infants? Premature infants usually have pulse oximetry measured as a routine part of their management and are observed for longer periods than asymptomatic term infants. Routine care in the NICU typically does not involve preductal and postductal oxygen saturation measurements, and the presence of lung disease and other illness makes oxygen saturation data more difficult to interpret. Therefore, some forms of CCHD may go undetected even in the NICU. CCHD screening at 24 hours after birth is frequently not possible in the NICU, as preterm infants are often given supplemental oxygen. The Canadian Paediatric Society (2017) says that pulse oximetry screening has not been adequately studied in preterm newborns or in the NICU setting relative to cut-off values for normal and abnormal. While pulse oximetry is an important monitoring tool for newborns with signs of CHD, the pulse oximetry protocol is intended for use in asymptomatic newborns in non-acute care settings. The AAP (2018) recommendation is that the CCHD screening protocol should be followed once the infant has been weaned from supplemental oxygen. Please follow the guidelines in your health authority. Breastfeeding Deciding whether to breast or formula feed is an important and personal choice and a balance between many different factors. These include antenatal influences, a previous breastfeeding experience, support, challenging situations such as breast surgery, or a return to work outside the home. Most health care providers acknowledge that breastfeeding is the best way to feed an infant because of the health benefits for both baby and mother. To make an informed decision, therefore, it is important to educate childbearing women and their families about the benefits of breastfeeding, anatomy of the breast, physiology of breastfeeding, sources of support and information, and alternative methods of feeding expressed breast milk. Empowering women with breastfeeding knowledge and skills will help them persevere when faced with common breastfeeding challenges. For example, women need to know that it is possible to breastfeed exclusively and to work outside the home by expressing and storing milk to be fed to the baby while they are at work. If a woman has had a previous unhappy breastfeeding experience, a conversation during pregnancy with a breastfeeding counsellor, lactation consultant or a La Leche League leader may be very helpful to understanding how breastfeeding could be different this time around. If a partner is concerned about not being able to feed the breastfed baby, it is helpful to recognize that he or she can still be involved in baby care and parenting, as well as supporting and encouraging the mother's efforts to breastfeed. Many women question their decision to breastfeed following breast surgery. Breastfeeding can be more difficult when a mother has had breast surgery. Previous breast surgery can involve either augmentation mammoplasty (breast implants) or reduction mammoplasty and may impact a mother's ability to breastfeed successfully (Lowdermilk et al., 2020). Women with breast implants should be able to exclusively breastfeed their infants if the implant is almost completely covered by the chest muscle. Women with breast reduction surgery many not be able to fully provide breast milk for their newborns due to interference with milk ducts, removal of glandular tissue and nerve damage (Lowdermilk et al., 2020). However, through the use of an alternative feeding method called a supplemental nursing system, these mothers can supplement using a commercial formula. Fluid and Electrolyte Balance All infants can experience problems with fluid and electrolyte balance. Total body water is very high compared to weight and total body mass. Infants are 80%--95% water; the lower the gestational age, the higher the total body water. Extremely preterm infants are almost all water. A term infant's renal system can manage to match urine output with body needs within a narrow range of normal. Too much or too little fluid can easily overwhelm a newborn's ability to maintain fluid and electrolyte balance. In James' case, he has experienced low oral intake, which will make him lethargic and slightly dehydrated. Among healthy term infants, this is a potential problem, especially if the problem goes unnoticed. It can quickly progress to more severe dehydration, poor perfusion, hypovolemic shock, and renal shutdown. Ill term infants and preterm infants are at even greater risk for fluid and electrolyte imbalance. Higher body water content, thinner skin leading to higher insensitive water loss from a larger surface area, more immature kidneys, and reliance on IV fluids are the main factors increasing vulnerability for these infants. All nurses working with newborns need to understand fluid and electrolyte balance. This enables the nurse to better anticipate, recognize and prevent potential fluid and electrolyte complications. Dehydration Infants are prone to dehydration because, compared to adults, they have more body water, more of that water is extracellular, their total body water turnover is higher, their evaporative water losses are higher, and their kidneys are less able to conserve water by concentrating urine. Dehydration can be lethal. Its early signs can be quite subtle, if noticeable at all. Left untreated for even a short time, dehydration can significantly increase an infant's morbidity and mortality. The incidence of dehydration in hospital has significantly decreased over the past two decades. Our abilities to recognize and manage dehydration have improved with new technologies, such as small bore central line tubing, total parenteral nutrition (TPN), and infant IV pumps. Infants in hospital rarely dehydrate (in contrast to infants like James), and because of this, you may not see a dehydrated infant for months or years after you begin practice. For this reason, it is important that you remember that all infants are at high risk for dehydration and the fact that it doesn't happen very often is a comment on the way we are doing our work. Ensuring adequate intake is the key to preventing dehydration. In James' case working on breastfeeding problems is the way to accomplish this. In a hospital setting, managing IV therapy and/or giving gavage feeds may be the appropriate interventions. The key to preventing dehydration is to do regular fluid and electrolyte assessments. Hydration assessment includes tissue turgor, mucus membranes, weight, fontanel, urine output, and serum sodium. Weight, in particular, is a key indicator of hydration status. Infant weight is a critical indicator of adequate intake. A weight loss of 5%--10% of the birth weight is considered acceptable in the first few days of life, before a mother's breast milk is well-established and while an infant is experiencing the diuresis that normally occurs after birth. Any additional weight loss beyond 10% is a cue to examine the situation more thoroughly. This initial weight loss should be regained within 7--10 days as muscle and fat if breastfeeding is going well (approximately 28--30 grams per day). Jaundice Jaundice is very common in newborn babies. It is usually easy to spot because the baby's skin and whites of the eyes turn a yellow colour. Babies become jaundiced when they have too much bilirubin in their blood. Bilirubin is a normal pigment made when red blood cells break down in the body. It is usually processed by the liver, recycled and eliminated in the baby's stool. When a baby has jaundice, it means either the body is making too much bilirubin or the liver is not getting rid of it quickly enough. Feeding (especially breastfeeding) in the first hours and days after birth helps reduce the risk of jaundice by promoting the passing of stool and the excretion of bilirubin. In term infants, jaundice commonly interferes with feeding patterns by making infants more lethargic and sleepy. It helps to emphasize with parents the relationship between jaundice and feeding, which looks something like this: Postpartum Mood Disorders The postpartum period is a time of increased risk for both women and men. It is estimated that approximately 15% of women and 4%--12% of men experience depression in the postpartum period (Gardner & Voos, 2021, in Gardner et al.). Although the actual number is likely underreported due to poor screening and underdiagnoses, especially in men. There are many risk factors associated with postpartum mood disorders, such as pre-existing depression, preterm birth, multiples, age (especially adolescence), low income and poor social support (see the table on p. 1,063 of your textbook for a comprehensive list of predictors). A review of the literature reports the usefulness of routine assessment using validated screening tools to help identify women (and men) who are at risk for, or actually suffering from, postpartum depression. Postpartum mood disorders are divided into three categories briefly described below. Postpartum Blues Often referred to as the "baby blues," postpartum blues affects 50%--80% of new mothers (Gardner & Voos, 2021). Postpartum blues are relatively benign and short term; symptoms include feeling sad, tearfulness, irritability, mood swings, anxiety, worry, and physical and mental exhaustion. These symptoms usually start within a couple days of birth and can generally last about two weeks. The cause of postpartum blues is not fully understood but is thought to be a combination of hormonal changes, exhaustion, and adapting to major life changes. If symptoms are severe or last more that two weeks, women should seek immediate help. Postpartum Depression Postpartum depression, while more severe, is still fairly common. Symptoms usually appear within the first month postpartum, and include lack of interest in usual activities, depressive mood, hopelessness, appetite disturbances, inability to sleep, irritability or anger, and even thoughts of self-harm and harm of the infant. Postpartum depression may initially be mistaken for postpartum blues, but the symptoms are more intense, last longer, and may interfere with the mother's ability to care for her baby. It is very important for women to be screened and treated early as postpartum depression can last for many months or longer and can negatively affect attachment, parenting and relationships. Postpartum Psychosis Postpartum psychosis is very rare but extremely serious and occurs in 1--2 per 1,000 births (Gardner & Voos, 2021). Postpartum psychosis is characterized by intense symptoms, such as delusions, hallucinations, extreme irritability, paranoia, sleep disturbances and hyperactivity, which usually occur within the first two weeks after birth. It is an emergency and requires immediate help due to the risk for self-harm and harm of the infant. Sibling Adjustment Another factor with which Claire is coping right now is Liza's adjustment to James. Caring for a 2½-year-old is time-consuming at the best of times, let alone when there is a new baby to feed every two hours. The birth of a sibling is a normal milestone for many families, but regardless, parents are always concerned about how to prepare their firstborn children for their new sibling. While most children cope quite well with the birth of a sibling, some children experience emotional and behavioural problems such as aggression, sleep problem, anxiety and withdrawal (Volling et al., 2019). Age also plays a big role in sibling adjustment in that older children are typically eager to meet the new addition, while younger children might be confused or upset. Regardless of the age of the child, we can encourage parents to make sure that older siblings still get individual attention when the new baby arrives! Concerns As you may have anticipated, all of the "stressors" Claire is experiencing related to depressed mood, pain, anxiety over Liza, and lack of time contributed to Claire's issues with breastfeeding. Difficulties with breastfeeding is causing both jaundice and dehydration for James. In all infants, a change in weight is one of the most critical indicators of hydration status. Continued monitoring of his weight, feeding and hydration status is essential. Hydration is assessed by monitoring weight, urine output, skin turgor, fontanel and mucous membranes. In addition, in hospital, serum sodium is a good indicator of hydration. Increased serum sodium often indicates loss of fluid from the body, leaving excess salt in the serum. Transition The transition from fetus to newborn is a critical time of adaptation because complex physiological changes must occur in a relatively short period of time. For most infants, this happens in an effortless and coordinated pattern, although in some infants there is altered or delayed transition. In these instances, careful assessment and management are urgently important in order to avoid serious consequences. RESPIRATORY SYSTEM: When an infant is born and the umbilical cord is clamped, the blood flow from the placenta is stopped and the infant must establish effective ventilation in order to maintain adequate oxygen levels. Many factors can influence the establishment of effective ventilation: - - - - - - The establishment of effective respiration is a complicated, multifactorial process. Factors include the catecholamine surge that occurs prior to the onset of labour, the postnatal decrease in 02 concentration, the increase in C02 concentration and decrease in pH that trigger the respiratory centre, the mechanical squeeze on the chest as the infant moves through the vaginal canal, and further expansion of the lungs as the infant cries (Askin, 2009). CARDIOVASCULAR SYSTEM: Profound changes occur in the cardiovascular system during transition from fetal to neonatal life. As we know, during fetal circulation, there is high pulmonary vascular resistance (PVR) and low systemic vascular resistance (SVR), as well as three shunts: 1. 2. 3. Let's briefly review fetal circulation. Oxygenated blood is delivered from the placenta to the fetus via the umbilical vein: - - - - - - At birth, the umbilical cord is clamped and the placenta is removed as the organ of gas exchange (along with the ductus venosus), and therefore the lungs must take over this role. Fetal fluid must be absorbed and alveoli expanded in order for the lungs to effectively take over oxygenation. Mechanical compression of the chest during birth creates negative pressure, drawing air into the lungs, and positive intrathoracic pressure created when the newborn cries keeps alveoli open and forces remaining fetal fluid out of the lungs. As oxygen enters the lungs, the pulmonary vascular bed dilates, allowing for increased blood flow to the lungs and decreased pressure in the right atrium. The left atrial pressure exceeds the right atrial pressure due to increased pulmonary venous return to the left atrium and less blood flow to the right atrium, which leads to functional closure of the foramen ovale. Blood is now following the path of right atrium to right ventricle to lungs. After birth, SVR rises and PVR falls, causing a reversal of blood flow through the ductus arteriosus. Instead of bypassing the lungs, blood is now sent to the lungs. Closure of the ductus arteriosus is due to a rise in P02 concentration after birth and a decrease in circulating prostaglandin levels (from removal of the placenta). Closure of the ductus arteriosus happens gradually, with 90% of infants having full closure by 48 hours of age; therefore, in the first days of life, there may be some bidirectional shunting of blood, depending on the levels of PVR and SVR. THERMAL ADAPTATIONS: The fetus expends no energy staying warm. After birth, the newborn's ability to stay warm relies on both internal and environmental factors. Newborns are predisposed to heat loss for various reasons: they have a large surface area in relation to their body weight, limited body fat, and decreased ability to shiver to stay warm. Term infants have several processes available to attempt to stay warm: increased muscle activity, non-shivering thermogenesis (burning brown fat), and peripheral vasoconstriction. Despite these processes, newborn infants rely tremendously on caregivers to monitor and maintain thermoregulation. Without caregiver support, infants will use up oxygen and glucose in an effort to produce heat; this yields lactic acid and can lead to metabolic acidosis, hypoglycemia, decreased surfactant production and poor growth. METABOLIC ADAPTATIONS: During fetal life, the infant has access to maternal glucose supplies, which freely cross the placenta. This provides the infant with enough energy to grow as well as to store glycogen in the liver for use after birth. Ultimately, blood glucose levels will drop without access to an outside source of nutrition, making the infant remarkably reliant on caregivers. Perinatal Asphyxia Perinatal asphyxia or intrapartum hypoxia-ischemia are terms used to describe impaired gas exchange or inadequate blood flow to the fetus/newborn that occurs during labour and delivery. Hypoxia and ischemia can lead to multi-organ damage and failure. Asphyxia can happen for a variety of reasons. A large percentage of asphyxia occurs prenatally when gas exchange through the placenta decreases as a result of problems such as: - - - - - - Fetal monitoring will often reveal an infant's response to antenatal asphyxia. Gas exchange can also be interrupted after birth, leading to asphyxia. Some disorders that affect gas exchange in a newborn are: - - - - - - Regardless of the cause, a sequence of events occur once a fetus or newborn has experienced intrapartum hypoxia-ischemia. Initially, inadequate gas exchange causes the blood O2 to decrease and the CO2 to increase. If the hypoxia (↓pO2) and hypercapnia (↑pCO2) are not corrected, but rather are allowed to progress, the result is a wide range of life-threatening conditions that affect almost all organ systems. Throughout this course, we will refer to this as the multi-system organ effects (MSOE) of hypoxia-ischemia. Infants have limited ability to respond to hypoxia but will attempt to provide their organs with oxygen in two ways: ALTERATION OF BLOOD FLOW: Alteration of blood flow is an attempt to provide those organs necessary for immediate survival---the brain and the heart---with as much oxygen as possible at the cost of non-vital organs (diving reflex). In order to do this, blood is shunted away from non-vital organs such as the lungs, intestines, kidneys, and peripheral vessels. The longer those organs receive less blood, the more damage they sustain. Unless the cause of the hypoxia is remedied, the heart and brain eventually also succumb and are damaged. TACHYCARDIA: An increase in heart rate is a reflection of the heart's effort to increase cardiac output in response to the decrease in blood oxygen levels. When the heart rate increases, the cardiac output and blood pressure are improved, therefore increasing perfusion and oxygenation. Keep in mind that newborn infants already have quite high heart rates in comparison to older children and adults. This limits their capacity to increase their heart rates and sustain that increase. Anaerobic Metabolism Hypoxia and asphyxia alter glucose production and utilization by requiring an increase in glycogeolysis to meet the increased metabolic and energy demands. Because oxygen availability is compromised, the infant switches from aerobic to anaerobic metabolism. Anaerobic metabolism is less efficient than aerobic metabolism and requires significantly more glucose to create energy. This rapidly depletes the glucose reserves; this decreased energy production is often inadequate to maintain normal cell processes and leads to the accumulation of lactic acid, which causes metabolic acidosis. Hypoxia will also lead to hypercapnia (↑CO2) due to the body's attempt to bring in more oxygen and will result in respiratory acidosis. Left uncorrected, these problems (hypoxia, hypercapnia, and acidosis) worsen. The result can be tissue and cell damage in all organ systems, and if enough cells in an organ are damaged, organ failure will result. In addition, if enough organs fail, death may ensue. Meconium Aspiration Meconium aspiration is a common feature of perinatal asphyxia for full- and post-term infants. Preterm infants, particularly those less than 32 weeks gestation, rarely experience meconium aspiration as their guts contain very little meconium. Full- and post-term infants, in contrast, have large amounts of meconium in their colons. Post-term infants are at particular risk for meconium aspiration for several reasons: - - -  When full- and post-term fetuses experience hypoxia, their gastrointestinal wall relaxes and meconium is expelled into the amniotic fluid. If the hypoxia is severe, the infant can gasp (even in utero), causing the meconium to be aspirated into the airways. When the infant begins breathing at birth, the meconium is further aspirated, leading to severe respiratory distress, hypoxia and hypercapnia. Meconium aspiration causes hypoxia in the neonate by: AIRWAY OBSTRUCTION: The glottis, trachea, and smaller airways are physically obstructed, resulting in atelectasis, air trapping and alveolar collapse. SURFACTANT DYSFUNCTION: Meconium deactivates surfactant and may inhibit surfactant synthesis, which results in atelectasis throughout the lungs. CHEMICAL PNEUMONITIS: The contents of the meconium can irritate the airways and parenchyma, causing the release of cytokines, which results in inflammation of the airways. INCREASED PULMONARY VASCULAR RESISTANCE: This occurs as a result of the hypoxia/asphyxia, which can result in the ductus arteriosus staying open (right-to-left shunting) and the maintenance of fetal circulation. Persistent Pulmonary Hypertension of the Newborn One complication Vinod is at risk of developing is persistent pulmonary hypertension of the newborn (PPHN). This problem can develop when perinatal asphyxia interferes with successful transition from fetal to postnatal patterns of circulation. Full- and post-term infants are particularly vulnerable to PPHN because the muscles in the walls of their pulmonary vessels are well developed and are highly sensitive to hypoxia. Preterm infants, while they can and do experience asphyxia, are less likely to develop PPHN because their pulmonary vessels are less muscularized and less sensitive to hypoxia. The development of PPHN significantly adds to an infant's vulnerability, morbidity, and mortality. Very briefly, this is why: a rising blood oxygen level is critical to successful transition. Recall that in utero, low pO2 levels help to keep the ductus arteriosus open and cause pulmonary vasoconstriction. Together, a patent ductus arteriosus and pulmonary vasoconstriction shunt blood away from the lungs (right-to-left shunting). During transition, rising pO2 begins to close the duct and causes pulmonary vasodilation, lung fluid is absorbed, and the lungs take over the process of gas exchange (which was previously done by the placenta). The following diagrams compare normal and impaired pulmonary blood flow. In the presence of hypoxia, pulmonary vasoconstriction continues, which in turn will maintain a patent ductus arteriosus that can lead to pulmonary hypoperfusion. This will continue the cycle of hypoxia and PPHN, a cycle that is very difficult to break. It is extremely difficult to treat this cycle, and infants with PPHN can experience profound ongoing hypoxia that can lead to significant multi-system organ damage. In addition to the added multi-system effects of asphyxia, infants like Vinod can experience increased illness. Neonatal Resuscitation Approximately 375,000 babies are born in Canada every year. Of these infants, 5%--10% require some form of resuscitation at birth to establish effective ventilation (PSBC, 2017). All of these infants are at risk for perinatal asphyxia and hypoxia. The transition from intrauterine to extrauterine life is fraught with risk. Specifically, the cardiorespiratory changes that begin at birth and continue for the first several hours after birth are critical to an infant's health and survival. Failure to make this transition produces a number of serious health challenges, many of which have been discussed in this module. Birth and the transition to extrauterine life are sources of vulnerability for all infants. For this reason, every birth should be attended by a healthcare provider whose primary role is to assist the baby during transition. This includes the ability to provide positive pressure ventilation and chest compressions. This is a guiding principle for the Neonatal Resuscitation Program (NRP), endorsed by the Canadian Paediatric Society, the American Academy of Pediatrics, and the Canadian and American Heart Associations. This program, which you will complete prior to doing your clinical time, provides the foundation for neonatal resuscitation throughout North America. NRP incorporates the ABCs of resuscitation: - - - Most newborns will require only the initial steps in resuscitation (stimulating and assessment); however, a very small number (less than 1%) will require increased resuscitation efforts (chest compressions and medications). A basic premise of NRP is that the best way to provide a high level of competent resuscitation is by ensuring each delivery room is properly equipped and the appropriate numbers of personnel skilled in neonatal resuscitation are available for each delivery. At least one person skilled in neonatal resuscitation should attend every delivery. One person with the skills required to perform a complete resuscitation, including intubation and delivery of medications, should be available. The assistance of a third person is highly desirable when it is necessary have IV access and give medications. The Apgar Score In 1953, a physician named Virginia Apgar developed a scoring system for assessing the condition of infants at birth. The categories and scores are as follows: **0** **1** **2** ------------------------ ------------ ----------------------------- ------------------ **Heart rate** absent below 100 above 100 **Respiratory effort** absent slow, irregular good, crying **Muscle tone** limp some flexion active, reflexed **Irritability** none grimace cough or sneeze **Colour** blue, pale body pink, extremities blue all pink An infant is given a score in each category at 1 and 5 minutes (and sometimes at 10 minutes). The highest score possible would be 10 (a score of 2 in each category). **pH** **7.17** --------------- ---------- pCO2 61 p02 35 Bicarb 17 Base excess −5 Blood glucose 2.9 Blood Gas Analysis Blood gas analysis is a very useful tool and is used when caring for infants who have been or are suspected to have been asphyxiated. Throughout this course, blood gas analysis will be discussed within the context of each case. In this module, we will review blood gas analysis theory and apply it to Vinod's situation. \*Please note - depending on the literature, normal blood gas values may vary slightly, especially the HC03 and the BE. For the purposes of this course, we will use the below range for normal blood gas values. **Normal Values for Blood Gases** ----------------------------------- ------------ pH 7.35--7.45 pCO2 35--45 PaO2 50--80 HCO3- 20--26 BE -4 --+4 Blood gas analysis assesses three interrelated but separate processes: oxygenation, ventilation, and acid--base homeostasis. OXYGENATION: Oxygenation is assessed by how much oxygen the lungs are delivering to the bloodstream, indicated by the pO2 and oxygen saturation. - - - - - - VENTILATION: Alveolar ventilation is determined by the pCO2 level. Carbon dioxide is very sensitive to minute ventilation, which is the volume of air inspired and exhaled in a minute. Minute ventilation (tidal volume × rate) and, in particular, tidal volume (volume of air moved with each breath) is affected by the functioning of the pulmonary system. - - - - - Acid--Base Homeostasis Acid--base homeostasis is the balance of acid to base necessary to keep the blood pH level normal. The acid--base balance of an infant's blood is reflected by the pH: - - - Acid--base imbalances are categorized as having either a respiratory, metabolic or mixed component. Depending on the pH, they are also categorized as being acidotic or alkalotic. +-----------------------------------+-----------------------------------+ | **Respiratory Acidosis** | **Metabolic Acidosis** | +===================================+===================================+ | Caused by: | Occurs with hypoxia and/or poor | | | perfusion caused by: | | - - | | | | - - - - | +-----------------------------------+-----------------------------------+ Alkalosis is a far less common neonatal response to illness than is acidosis. Both respiratory and metabolic acidosis are common neonatal blood gas abnormalities. Occasionally, respiratory alkalosis is seen in an infant who is hyperventilating, either spontaneously or by a mechanical ventilator set with too high a rate. Metabolic alkalosis will rarely be seen. SEIZURES: Neonatal seizures are quite different from seizures in older children and adults. This is primarily due to an infant's immature cerebral cortex. When an infant has a seizure, it is often quite subtle and therefore may be missed. A neonatal nurse is frequently the only person who observes the abnormal clinical signs that suggest seizure activity. For this reason, the nurse's observations during the episode play a key role in assisting in the diagnosis and treatment of seizures. Knowing the classification (for example, clonic vs. tonic, etc.) of seizure activity is not essential. What is important is that you know what to look for and how to distinguish seizure activity from jitteriness or other non-seizure activity. Seizures are usually accompanied by abnormalities of gaze or extraocular movement. Seizures are not stimulus sensitive---if you touch an infant and the infant responds with his/her arm shaking, the infant is jittery, not having a seizure. The dominant movement in a seizure is clonic jerking, in that the movements have a fast and slow component. Seizure movements will not stop if you flex the affected limb, while jitteriness will stop. In addition to differentiating seizure activity from jitteriness and other abnormal non-seizure movements, it is very important that you describe the seizure activity accurately. Aspects to consider are the following: - - - - - - - Determining the cause of seizure activity is important. This ensures that treatment of the underlying condition (if it is treatable) begins immediately. Causes of seizures are: - - - - - - If you suspect that an infant is having a seizure: - - - - - - - - - Family-Centred Care in the NICU Family-centred care is absolutely essential in providing high-quality neonatal care. It is not an "extra" but rather the foundation of everything we do in the NICU. Providing family-centred care in the NICU means that we treat all families with dignity and respect, share information, encourage parental participation in care, and collaborate with families in all aspects of planning and implementing care. Prematurity: A Source of Vulnerability Prematurity significantly increases an infant's vulnerability. This is because a preterm infant's systems are less mature than a full-term infant's. This immaturity leads to dysfunction and an increased risk for damage by the extrauterine environment. The multi-system effects of prematurity can become progressive; as one or more systems experience dysfunction, other systems are often affected. Additionally, the ongoing negative side effects of treatment can worsen system dysfunction. The most common multi-system effects of prematurity include intraventricular hemorrhage (IVH), patent ductus arteriosus (PDA), respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), acute kidney injury (AKI), sepsis, hyperbilirubinemia, hypothermia, hypoglycemia, and apnea. Of these multi-system effects, RDS is particularly worrisome. Although other equally serious pulmonary problems do occur, they do so with less frequency. RDS is the most common cause of respiratory distress for preterm infants. The long-term sequelae can be significant. Over time, as immature systems grow and develop in the extrauterine environment, these systems can be permanently damaged. Respiratory Distress Most hospital nurseries are heavily populated with premature infants who are either experiencing, or are at risk for experiencing, respiratory distress. Respiratory distress can have many different causes; however, in preterm infants the most common cause is Respiratory Distress Syndrome (RDS). RDS is a potentially life-threatening problem, largely because of the pathophysiology that results from immature pulmonary structure and function. The following discussion is intended to introduce you to the pathophysiology underlying RDS, including how infants typically respond to this problem, what the signs are, and the implications for assessment. Health Promotion Practice Implications As you will learn in the case that follows, at 34 weeks Sarah is at risk for all of the multi-system effects of prematurity. Her care should be aimed at anticipating these problems and preventing them from occurring in the first place. At birth, and shortly after, Sarah is still unstable; the immediate focus must be on stabilization. We must also constantly be thinking about and providing developmentally supportive care. This is not a "nice to have"; this is a "must have" with every single interaction, with every infant we care for. We know that the NICU environment is traumatic for both infants and families, and we also know that this trauma has the potential to lead to serious and life-long consequences. As neonatal nurses, we must aim to mitigate this trauma. Consider that NICU nurses are intimately connected to infants and their families during critical and sensitive periods of development. The care provided leaves an impression, good or bad, that has the potential to impact future outcomes of these tiny beings. The responsibility we have is enormous, and the importance of developmentally supportive care must not be minimized. Trauma-Informed, Age-Appropriate Care in the NICU Trauma-informed care is a concept that is widely used in mental health to describe the understanding that traumatic events such as abuse and neglect can lead to long-term physical and psychological effects. The term "age-appropriate care" was introduced in order to assist caregivers in recognizing that patient needs over the different stages of life change, requiring care that adjusts with his or her developmental, biological, and socioemotional needs (Coughlin, 2014; Raja et al., 2015). Trauma-informed, age-appropriate care is, "a developmental concept that recognizes the physiological, neurobiological, and psychoemotional sequelae of trauma in early life and aims to mitigate the deleterious effects associated with the trauma experience through the provision of evidence-based, age-appropriate caring strategies" (Coughlin, 2014, p. 29). In the NICU environment, infants are frequently exposed to experiences such as maternal separation, pain, stress, isolation, sleep deprivation, anxiety, and fear. All of these traumatic experiences have the potential to contribute to significant and permanent psychological and emotional damage (Coughlin, 2014; Petchel & Pizzagalli, 2011; Lieberman et al., 2011). Core Measures for Age-Appropriate Care in the NICU HYPOXIA: The important role that oxygen plays in neonatal health and illness makes it worth discussing oxygenation apart from respiratory distress and blood gas analysis. It is important to remember that oxygen is vital to life; without oxygen, cellular processes do not function optimally and with prolonged hypoxia, cell damage and death can occur. Hypoxia: a deficiency in the amount of oxygen reaching the tissues Hypoxemia: a deficiency in the amount of oxygen in the blood Because oxygen is vital for all organ systems, a lack of oxygen---hypoxia---affects all organ systems. We will often refer to the multi-system organ effects of hypoxia as we discuss the various health challenges that arise from or are worsened by hypoxia. Oxygenation is, in part, dependent on adequate breathing. You will already know, from the previous discussion of respiratory distress, that many preterm infants experience difficulties with breathing. For this reason, most preterm infants are at risk for hypoxia and hypoxemia. Responses to Hypoxia Responses to hypoxia vary, depending on the severity and duration of the hypoxia. In general, there are early and late responses and these tend to be: Early Responses to Hypoxia Early responses to hypoxia suggest efforts to compensate. Specifically: - - - - Late Responses to Hypoxia Infants, unlike adults and older children, do not often demonstrate early responses to hypoxia for very long before they begin to decompensate and show late responses. Specifically: - - - - Hypoxemia Understanding early signs of hypoxia and respiratory distress are the key to preventing respiratory failure. Assessment of oxygenation includes monitoring for early and late signs of hypoxia. Respiratory rates, heart rates, skin colour, perfusion, and level of consciousness and activity all reflect how well an infant is oxygenated. Hypoxemia (low blood oxygen) can be assessed by looking at pO2 and SaO2 saturation (SaO2 measured by pulse oximetry is denoted as SpO2). Oxygen is carried in blood in two ways: Dissolved in Plasma - - - - Attached to Hemoglobin - - Pulse Oximetry - - - - - pO2 (Partial Pressure of Oxygen) - While both approaches are commonly used to identify the amount of oxygen in the blood, they each tell us about a different way that oxygen is transported. Hemoglobin Anemia (decreased hemoglobin) and polycythemia (excess hemoglobin) affect oxygen saturation interpretation. Hypoxia and Increased Vulnerability A key point that we will reinforce throughout the course is the idea that hypoxia significantly increases an infant's vulnerability. In this module, we see that Sarah's RDS and resultant hypoxia are putting her at risk for other health challenges, such as necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and intraventricular hemorrhage (IVH). This is because hypoxia is a major causative factor in the development of these other health challenges. Recall from previously in the module that the diving reflex redistributes blood away from the liver, lungs, skin, skeletal muscle, gut, and kidneys to the heart and brain, causing the non-vital organs to become hypoxic and ischemic. Sarah highlights how the combination of prematurity and hypoxia can lead to multi-system organ effects. When an infant is born preterm, all organs are vulnerable because of immature development and the untimely demands of extrauterine life. When hypoxia (usually due to RDS) with its multi-system organ effects is added to the situation, the risk that pathology will develop in multiple organ systems becomes higher. Understanding these relationships enables neonatal nurses to predict and anticipate the kinds of problems preterm infants are at risk for. This, in turn, enables nurses to tailor assessments and care in a way that anticipated problems can be prevented and/or detected early. In particular, in this case, it is important to know that the risks for Sarah developing PDA, NEC, and renal failure are significant, as is the risk for sepsis. Sepsis All infants, preterm, full term and post term, are at risk for sepsis. Infants' immune systems are often described as *immature and inexperienced*. Not only are infants at high risk for developing infection, once established, infection can progress alarmingly quickly and can have life-threatening consequences. For these reasons, prevention, early recognition, and appropriate treatment of infection are important aspects of neonatal nursing. Nursing care of infants should include monitoring for signs and symptoms of sepsis as well as prevention of sepsis: - - - - - INFECTION CONTROL: You will learn more about these policies when you complete the first clinical course; however, for now, it is important for you to appreciate that an infant's environment can be a significant source of microorganisms. This includes equipment, hands, linen, diapers, and anything and everything that comes in contact with an infant. Because there are so many points of contact, combined with an infant's immature and inexperienced immune system, infection control is an important part of neonatal nursing. Good handwashing, clean and aseptic techniques, and appropriate use of sick time are just a few examples of nursing practice that are aimed at preventing infection. Think of each infant as being on contact isolation. For those infants who require a greater degree of isolation, a separate room and strict isolation practices may be necessary. Microorganisms that may be endemic and either harmless or somewhat harmful in the adult population can be life threatening in the neonatal population. Hypoglycemia Hypoglycemia is the most common metabolic disturbance occurring in the neonatal period. Screening at-risk infants and the management of low blood glucose levels in the first hours to days of life is a frequent issue in the care of the newborn infant. Immediately after birth, infants must adapt to the loss of a constant supply of maternal glucose. Glucose is the main source of energy for brain cells. Maintaining an adequate blood glucose concentration is essential because neurologic compromise can occur if the brain is deprived of glucose. If an infant is at-risk or unwell, a blood glucose of less than 2.6 mmol/L in the first 72 hours of life indicates the need for active management and ongoing surveillance. Beyond 72 hours of age the threshhold for treatment increases to 3.3 mmol/L. In well term infants routine glucose monitoring is not recommended. These infants may have a transient decrease in glucose levels in the first 2 hours of life, but their internal counter-regulation mechanisms will meet their needs as feeding is established. A key idea is that when infants are experiencing hypoxia, they shift from aerobic metabolism to anaerobic metabolism. Glycolysis is the major pathway of glucose metabolism; during anaerobic metabolism, the rate of glucose formation (through glycolysis) is significantly reduced. In fact, anaerobic glycolysis produces only two molecules of the energy molecule (ATP) per molecule of glucose, as compared to 36 molecules during aerobic oxidation. This means that 18 times more glucose is required to produce the same amount of energy during periods of hypoxia. Furthermore, while both aerobic and anaerobic metabolism burn the same major intermediary substrate (pyruvic acid), anaerobic metabolism converts pyruvic acid to lactic acid. Aerobic metabolism further metabolizes pyruvic acid for extra energy (hence the 38 moles of ATP). Nursing care and monitoring for hypoglycemia should include: - - - - - - - - - - Hyperglycemia Hyperglycemia in infants occurs less frequently than hypoglycemia but has the potential to have adverse outcomes, including increased mortality, sepsis, vision problems, reduced growth, white matter injury and intraventricular hemorrhages. Hyperglycemia is usually defined as a blood glucose \>10 mmol/L and is much more common in preterm infants than late preterm and term infants. Preterm infants have limited insulin secretion capacity, which limits glucose disposal and activates hepatic glucose production, both of which lead to hyperglycemia. Furthermore, many preterm infants are growth restricted and have experienced, or do so after birth, intermittent to persistent hypoxia, which increases secretion of catecholamines (largely norepinephrine) that further suppress insulin secretion. Intermittent hypoxia and other forms of stress also increase hepatic glucose production via increased secretion of cortisol, glucagon, and growth hormone. Administration of catecholamines and glucocorticoids also contributes to hyperglycemia. Absence or delayed onset and slow advancement of enteral feeding, all common in very preterm infants, limit production of gut incretins and their potential stimulation of insulin secretion (Hay & Rozance, 2018). Care is aimed at lowering blood sugars and can include changing the fluids, treating sepsis, medications (eg: insulin infusion) and providing developmentally supportive care. Physiology of Oxygen Supply and Demand The physiology of oxygen supply and demand is foundational knowledge in neonatal nursing practice. Simply put, if the body's cells are not supplied with the oxygen they need (demand), they will not be able to function properly. And, if oxygen supply is inadequate for long enough, cells will die. In the normally functioning body, the processes of oxygen supply and demand are a finely tuned balancing act. In order to ensure that the cells of all body organs receive the oxygen needed to fulfill their function, the body responds to and adjusts multiple factors that influence oxygen supply and demand. It is important to note that infants (especially preterm infants) have limited ability to respond to changes in oxygen supply and demand, and can quickly decompensate. So, when we look at whether oxygen supply is able to meet oxygen demand for a critically ill infant, we're not just interested in whether or not the lungs and heart (major components determining oxygen supply) are working effectively, but we're also concerned about perfusion of all body organs. The balance between oxygen supply and oxygen demand is therefore a global or whole body issue. The interrelationship of all body organs is the key factor that makes oxygen supply and demand a global issue. Because all organs are interrelated, inadequate supply in one organ will impact the functioning of others. Oxygen is required for the normal intracellular processes that produce the energy necessary for the cell's function. A lack of oxygen forces the cell to switch to anaerobic metabolism---an ineffective system that is limited in its ability to meet the cell's energy needs. The resulting lack of energy leads to failure of cellular functional processes and, ultimately, cell death. 1. 2. 3. - - - OXYGEN AND SUPPLY DEMAND BALANCE:  We begin our exploration of oxygen supply and demand by looking at factors that influence arterial oxygen saturation. Three factors that influence arterial oxygen saturation are: 1. 2. 3. The concentration of inspired gas Fi02 can clearly have an effect on arterial oxygen saturation in presence of normal cardiovascular anatomy, the higher the Fi02, the higher the arterial oxygen saturation (as long as there is adequate gas exchange). Below we will discuss more in-depth the role of ventilation and alveolar gas exchange on arterial oxygen saturation. Oxygen The difference in concentration of oxygen in the alveoli and in the capillary (termed driving pressure) supports the movement of oxygen from the alveoli to the pulmonary capillary. We increase the driving pressure of oxygen whenever we administer supplemental oxygen to infants via nasal prongs or through CPAP or a mechanical ventilator. The movement of oxygen across the alveolar-capillary membrane is influenced by two processes: ventilation and diffusion. Let's look at both of these processes. Distribution of Ventilation and Perfusion Effective diffusion of gases, especially oxygen, is only one part of optimal gas exchange. Gas exchange (and, therefore, oxygenation) is also affected by the relationship between ventilation and perfusion. Optimal gas exchange occurs when ventilation and perfusion of alveoli are well matched. The key point to grasp in considering the relationship between ventilation and perfusion in the lungs is that they both will be greatest in the dependent areas of the lungs. In other words, when an infant is upright, airflow (ventilation) and blood flow (perfusion) favour the lower portions of the lungs. When we position an infant on their right side, the right lung (especially the part nearest the bed) receives the greatest proportion of the air and blood flow. The influence of position on distribution of perfusion and ventilation in their lungs (and subsequently on arterial oxygen saturation) is an important consideration for neonatal nurses. Oxygen Transport Oxygen Transport: How Is Oxygen Transported? Oxygen is transported in the blood in two forms: approximately 2% is dissolved in plasma (reflected in PaO2), while approximately 98% is bound to hemoglobin (reflected in SaO2). These two forms of oxygen transport are strongly interrelated and are both essential to ensure adequate cellular oxygen supply. Hemoglobin, therefore, is the workhorse of oxygen transport. Approximately 98% of oxygen is carried to the tissues by hemoglobin. In essence, oxygen that is transported in bound form acts as a "reservoir" or bulk supply of oxygen for the body, while the oxygen in solution is "ready for use." If hemoglobin is what transports oxygen throughout the body, what happens when an infant has low hemoglobin? How does this affect his/her oxygen-carrying capacity and pulse oximeter reading? In this case, an infant may have a normal oxygen saturation reading (Sp02) but still be experiencing hypoxia at the tissue level due to decreased capacity to carry oxygen. That is, the available hemoglobin is well saturated with oxygen, but the levels of hemoglobin are not sufficient for adequate oxygenation. The Oxyhemoglobin Dissociation Curve The oxyhemoglobin dissociation curve reflects the relationship between oxygen and hemoglobin. We'll start with why we are even interested in the dissociation of oxygen and hemoglobin! As noted earlier, oxygen that remains bound to hemoglobin cannot participate in cellular metabolism---and so, oxygen and hemoglobin need to dissociate from each other in order to be useful in the body. The efficiency of the oxygen transport system depends on the ability of the hemoglobin molecule to bind oxygen as it passes through the lung and to release it at the tissue level on demand. The ease with which hemoglobin will bind and release oxygen is influenced by the "affinity" between these molecules: when affinity is increased, hemoglobin binds oxygen readily but is slower to release it; when affinity is decreased, it does not bind oxygen as readily but it releases it easily. Thus, as affinity changes, the relationship between oxygen and hemoglobin changes. Oxyhemoglobin Dissociation Curve Shifts Hemoglobin essentially works as a buffer system (or reservoir) that regulates oxygen levels in the tissue cells. In order to be able to release oxygen "on demand," it is necessary that the affinity of hemoglobin for oxygen be able to change with the metabolic needs of the tissues. This change is represented by a shift in the oxyhemoglobin dissociation curve to the right or left. These shifts are shown in the image above as red, blue, and green curves. Notice that, as the curve shifts to the right (green curve), the PaO2 is greater for any given level of SaO2 compared to the blue curve (the normal curve). In other words, as the curve shifts to the right, proportionally *more* bound oxygen is released into solution. How does that happen? Well, *as the curve moves to the right, the affinity of hemoglobin for oxygen is reduced, favouring release of oxygen into solution,* which increases the availability of oxygen to the tissues. The most common conditions that cause the curve to shift to the right (and a decrease in affinity) are fever, acidosis (decreased pH), or an increase in PaCO2. These all reflect increased tissue metabolism and increased cellular need for oxygen. We can remember the effects of a right shift in the curve with a simple phrase: *"Right releases."* Now look at the red curve in the picture. Notice that, as the curve shifts to the left, the PaO2 is lower for any given level of SaO2,when compared to the blue curve. In other words, as the curve moves left, proportionally *less* bound oxygen is released into solution. *A shift of the oxyhemoglobin dissociation curve to the left represents an increased affinity of hemoglobin for oxygen* and occurs in situations associated with a decrease in tissue metabolism and, therefore, lower cellular oxygen need. Common conditions associated with a shift to the left include decreased temperature, alkalosis (increased pH), and decreased PaCO2levels. We can remember the effects of a left shift in the curve by noting that *"left shift has all the Ls"* (Low temperature, aLkalosis, Low PaCO2). It is important to note that fetal hemoglobin is the main oxygen transport protein in the human fetus and persists in the newborn until roughly 6 months old. Adult hemoglobin starts to be produced in utero, at around the 13th week of gestation. Initially in small amounts, its concentration gradually increases until 20%--30% of the baby's hemoglobin is adult hemoglobin. Functionally, fetal hemoglobin differs most from adult hemoglobin in that it is able to bind oxygen with greater affinity than the adult form, giving the developing fetus better access to oxygen from the mother\'s bloodstream. This means that the neonate's oxyhemoglobin dissociation cure is shifted to the left, meaning that the PaO2 is lower than adults with similar oxygen saturations; therefore, a neonate's normal Pa02 level (50--80) is lower than an adult (\> 80). Oxygen Demand Oxygen demand refers to the amount of oxygen a cell needs to provide the needed energy for its function. All cells have their unique demand or need for oxygen. Oxygen consumption is the amount of oxygen a cell consumes in order to function. If oxygen supply is adequate, then oxygen demand and oxygen consumption will be the same. However, when oxygen supply is limited for some reason, the oxygen consumption may actually be less than the real oxygen demand of the cell. The factors that most commonly increase metabolic and oxygen demands are increased temperature, increased activity, and stress. Conversely, metabolic and oxygen demands are decreased when activity is reduced, temperature is lowered, or stress diminishes. Hyperoxia in Preterm Infants Supplemental oxygen plays a critical role in the management of infants born prematurely, but it is not without risk. There has been a great deal of research on the topic and it is very clear that hyperoxia is linked to the development of severe retinopathy of prematurity (ROP), chronic lung disease, and brain injury. When preterm infants are exposed to high levels of oxygen, even for brief periods, it can result in oxidative stress and production of oxygen free radicals. If uncorrected, hyperoxia has the potential to induce a persistent oxidative stress cascade that outlasts the duration of exposure. Preterm infants lack adequate protective antioxidant levels, allowing exposure to hyperoxia to culminate in serious and often irreversible sequelae (Deuber & Abbasi, 2013). Our understanding of the ideal oxygen saturation is still evolving. As NICU nurses, we need to understand the importance of avoiding both hypoxia and hyperoxia, bearing in mind that the consequences of both are not only multi-system but also potentially life-long lasting. There have been several recent research trials that aim to better understand the effects of targeting lower (85%--89%) or higher (91%--95%) oxygen saturations. Some significant findings were an increased risk of death prior to discharge in the lower sat groups, decreased rates of ROP in the lower sat groups, and reduction in supplemental oxygen at lower post-natal age in the lower 02 sat group (Newnam, 2014). Based on this research, one recommendation is to maintain preterm infants' oxygen saturations at 87%--94% until vascular maturation of the retina, and adjust upward as the infants nears term (Newnam, 2014). Intrauterine Growth Restriction: A Source of Vulnerability Small for gestational age (SGA) infants are those in the lower 10th percentile for weight based on gestational age (Gardner et al., 2020). SGA infants can be genetically small but they can also suffer from intrauterine growth restriction (IUGR). The terms SGA and IUGR are often used interchangeably but the distinction between the two is important: - - The term IUGR should be used when there is evidence of abnormal genetic or environmental influences affecting growth. Thus, infants can be SGA without IUGR, and infants can suffer from IUGR and not be SGA (10% percentile or lower). Prenatal growth can seriously affect neurodevelopmental outcomes of infants. The neurodevelopmental outcomes of IUGR infants are strongly associated with the cause of IUGR. Early, severe IUGR often reflects a chromosomal abnormality, another severe genetic disorder, or a congenital infection that occurred early in gestation. Uteroplacental insufficiency is one of the most common causes of IUGR. The fetus will respond to a lack of oxygen supply and nutrients first by decreasing subcutaneous tissue, then by decreasing in length, lastly the head and brain growth will be affected (Gardner et al., 2021). There are two types of IUGR: - - - - - - - IUGR infants at full term show more language problems, learning disabilities, neuromotor dysfunction, hyperactivity, and attention and behaviour problems than full-term infants of an average size. Preterm infants who are also IUGR demonstrate the disadvantages of both prematurity and IUGR, showing higher rates of major disability and learning disability (Gardner et al., 2021).  Apnea Apnea is defined as a non-breathing episode lasting longer than 20 seconds and accompanied with cyanosis and/or bradycardia (Gardner et al., 2021). Neonates have a unique response to hypoxemia and CO2 retention. Adults will have a sustained increase in ventilation, but infants will have a brief period of increased ventilation followed by respiratory depression (Gardner et al., 2021). There are two types of apnea: - - When referring to apnea in the context of neonatal resuscitation, primary apnea responds to the initial steps of Neonatal Resuscitation Program (NRP), whereas secondary apnea does not respond to stimulation, drying, or suctioning and requires initiation of intermittent positive pressure ventilation (IPPV). Respiratory Support: Apnea Respiratory support is a priority for any infant. Without ventilation and oxygenation, cells, tissues, and systems will be affected. With ongoing respiratory dysfunction, cells, tissues, and systems fail and the infant can eventually die. In this case, Austin is experiencing apnea, which will interfere with both ventilation and oxygenation. Apnea can be fairly benign, if managed appropriately. Or apnea can progress to bradycardia, terminal apnea, and respiratory failure. Responding quickly and appropriately to an infant who is apneic is one of the most important nursing interventions. Assessment and intervention should proceed in an orderly sequence, although as you become more experienced you will start to look at everything simultaneously. Caffeine Citrate Methylxanthines (caffeine citrate, theophylline, aminophylline) are the primary treatment option for apnea of prematurity (AOP). They are cardiac, respiratory, and CNS stimulants and smooth muscle relaxers, with the effect on apnea being related to the CNS stimulation. Caffeine citrate is the drug of choice for AOP for a few reasons: once a day dosing, earlier onset of action, wide therapeutic range, no alterations in cerebral blood flow, and fewest side effects (Gardner et al., 2021). Caffeine citrate is also used prophylactically in premature infants. Studies have shown benefits such as improved BP, less time spent on mechanical ventilation or CPAP, and reduced risk for Patent Ductus Arteriosus (PDA), chronic lung disease, and kidney injury. Nursing care aimed at supporting and monitoring an infant's respiratory status should include: - - - - - - Feeding Concerns At 31 weeks, Austin's gastrointestinal system is still immature. How do we ensure safe feeding and adequate nutrition when caring for premature infants? Keeping him NPO until he is full term is not an option. As is the case for many other aspects of neonatal care, the decision to feed preterm infants must consider the relative risks and benefits. Nutritional Support Feeding decisions are not easy or straightforward. And yet they are critical to a vulnerable infant's health. Some infants should be NPO and not fed at all. Those are infants who: - - - - - - Research has demonstrated that immediate parenteral support and early enteral feeding are fundamental in neonatal management. Early enteral feeding has been shown to support GI development, somatic growth, metabolic homeostasis, prevention of infection, neurological development, and future health (Gardner et al., 2021). There is a growing amount of evidence that strongly supports early initiation of low-volume enteral feeding, also called "trophic feeds" or "gut priming." This early enteral feeding should be started within the first two days of life and be given in small volumes every 4--6 hours for several days. Trophic feeds are most effective with colostrum and breast milk (Gardner et al., 2021). Please see box 17-11 on page 520 of your textbook for a comprehensive list of advantages of minimal enteral feeding. Infants who are NPO or are not on full feeds require IV nutrition. D10W will provide sugar and water, but does not provide protein, fat, and electrolytes. If an infant will be NPO for an extended period, TPN should be given. Some infants cannot breast or bottle feed due to illness or immaturity, but can be fed by an oral or nasal gastric tube. Infants fed by a gastric tube are at risk for intolerance because they have no control over the amount or frequency of feeding. They must be closely observed for tolerance of feeds. In this module, we focus on intravenous (IV) therapy as an approach to infant nutrition. At 31 weeks, Austin's immature gastrointestinal system may not tolerate enteral feeds well. Being stressed in utero means that his GI system may have experienced hypoxia, putting him at risk for necrotizing enterocolitis. In addition, he does not have adequate suck/swallow/breathe coordination as this does not develop before 33--36 weeks gestation. It may take several days or weeks for Austin to get to full enteral feeds; in the meantime, he would require IV therapy for calories, fluid, and electrolytes. Donor Human Milk There are various reasons why an infant may need to be started on donor human milk (DHM), such as a low supply of maternal breastmilk or the mother has chosen not to pump. Over the years, the use of DHM has allowed us to replace formula for enteral feeding when maternal breastmilk is not available. It is recognized that DHM is the best replacement for mother's milk, with infant formula offering a third option if needed. The use of DHM has been shown to reduce the incidence of necrotizing enterocolitis in preterm infants in comparison to preterm formula (Gardner et al., 2021). It has been found that both premature birth and delay in the onset of breastfeeding contribute to decreased maternal milk production. When added to the stress of having an infant in the NICU and the fact that breast pumps are not as efficient at removing milk as a breastfeeding infant would be, it is understandable that mothers of preterm infants would have an increased likelihood of low milk production (Gardner et al., 2021). The trauma of preterm birth can also cause a delay in the mother's ability to start hand-expressing and pumping. Donor milk is breastmilk that has been pasteurized and usually frozen for distribution to hospital units. In BC, several public health units across the province act as collection depots for approved donors to drop off their milk. Donors are screened via a verbal and written questionnaire and are required to take a blood test. The milk bank for BC is located at BC Women's Hospital. Donated milk is pooled together during the pasteurization process and bottled according to batch number. Therefore, when an infant is receiving donor milk, they are receiving milk from many different sources. We know that there are living components in breastmilk, such as the biologically active proteins, that are reduced during the pasteurization process so you may see extra fortification added to donor breastmilk if an infant is going to be on it for an extended period (Pound et al., 2020). Some infants are only on DHM for the first few days of life while the maternal milk supply is established, while some are on it for a prolonged period until they no longer qualify to receive it. It is important to familiarize yourself with the criteria at your site for when an infant qualifies to receive donor milk. When it has been established that an infant qualifies for donor milk, it is important to have a conversation with the parents and ensure that they fully understand why the clinical team is recommending the infant receive DHM and to ensure that they sign a consent for their infant to receive DHM. If DHM is being used to supplement a low maternal supply, it is also important that you assess ways that the mother's milk supply can be increased, referring to the hospital lactation consultants if available. You may also encounter parents who want to participate in informal milk sharing. This is when milk is acquired by the parents and it has not been pasteurized or screened by a regulated source. The Canadian Paediatric Society does not endorse informal milk sharing as there are several risks associated with giving milk that has not been through a full screening and pasteurizing process. In BC, many health authorities have created acknowledgement of risk forms for parents to sign if they are choosing to use breastmilk acquired through informal milk sharing. The right of parents to make informed decisions regarding the care of their children is generally respected within the context of Canadian law, even if the decision is contrary to medical advice (Perinatal Services BC, 2016, p. 3). Intravenous Therapy There are several indications for initiating intravenous (IV) therapy in infants, and they include: - - - - An important aspect of caring for infants receiving IV therapy includes preventing complications. The following discussion provides an overview of the major complications of IV therapy for infants. Complications of IV Therapy for Infants - - - - - - - - Total Parenteral Nutrition Nutrition is a very important aspect of care for premature and ill newborns. Early nutritional support is very important as the infant's rapidly growing brain requires adequate nutrition to avoid irreversible negative neurodevelopmental outcomes. As we have learned, preterm infants require thoughtful introduction and advancement of enteral feeding. While we are increasing the amount of enteral feeding, we need to make sure we are providing everything the infant needs in terms of nutrition. This is where TPN becomes important. Infants require a certain amount of calories, water, electrolytes and minerals, carbohydrates, protein, fat, vitamins, and trace minerals. TPN is complex, but very simply, it is composed of an amino acid and dextrose solution that has electrolytes, minerals, vitamins, and trace elements added to it, which are ordered individually based on the infants needs. Lipids are also a key part of TPN as a source of fat. Traditionally, lipids have been made from soybean oil, but there are newer emulsions available that contain a mix of soybean oil, fish oil, medium chain triglycerides, and olive oil (Gardner et al., 2021). TPN solutions are prepared in the pharmacy under sterile conditions, and proper administration is vitally important. The formulation and patient identifiers should be thoroughly checked prior to administration, and the solution should be hung and changed based on your unit's policy. TPN is not without risk---there are many possible complications, including issues with glucose metabolism (hypo/hyperglycemia), problems with amino acid metabolism, cholestasis, hyperlipidemia, and infections. Standardized Feeding Guidelines You will likely see standardized feeding guidelines on the unit where you work. These might be in the form of weight-based feeding plans, or volume-based feeding plans. The importance of providing adequate nutrition to preterm infants cannot be overstated. It affects every sense of their growth and development and influences long-term outcomes. In the past, we have been very careful and conservative with the advancement of enteral feeding. This leads to longer central line access, intravenous access, exposure to total parenteral nutrition, and potential deficiencies in the nutrition provided. There is no clear evidence that supports a particular timing of initiation and advancement of feeding in preterm infants, but there is emerging evidence that supports more aggressive feeding advancement among preterm infants, without increasing the risk for NEC and feeding intolerance (Morgan, Young & McGuire, 2015). Standardized feeding guidelines are evidence-based, generally well tolerated, and offer a clear and consistent approach to feeding, feeding advancement, and fortification of breast milk in preterm and low birth weight infants. Necrotizing Enterocolitis Necrotizing enterocolitis (NEC) is a disease that primarily affects premature infants and is the leading cause of death due to gastrointestinal disease in preterm infants. The pathophysiology is complex and thought to be multifactorial but there are common factors that increase the risk for NEC (Meister et al., 2020): - - - - - - - - - - - - - - - - In preterm infants, the development of NEC is very much related to vulnerability arising from prematurity. Preterm infants lack many important GI defense mechanisms, such as gastric acid, digestive enzymes, mucous production, peristalsis, and immunoglobulin. Further vulnerability arises from delayed enteral feeding, early exposure to broad spectrum antibiotics, and formula feedings (Meister et al., 2020). In full-term infants, the development of NEC is related to vulnerability arising from the transition to extrauterine life. Asphyxia decreases blood flow to the gut, and if severe enough, can lead to ischemia and necrosis. NEC is characterized as a progressive disease of the gastrointestinal tract involving inflammation, infection, and necrosis of the bowel tissue. The causes are complex and many feel it is still poorly understood. The diagnosis and management of NEC are dependent on the disease severity but generally include broad spectrum antibiotics, bowel rest, and in severe cases surgical intervention. The focus should be on prevention, which includes early exposure to colostrum, skin-to-skin contact, developmentally supportive care, feeding breastmilk only and managing acid-base balance and hypoxia (Meister et al., 2020). Oral Immune Therapy Oral immune therapy (OIT) is the oropharyngeal administration (not enterally) of breast milk (preferably colostrum) in such small volumes that the infant does not need to swallow. A small amount of milk (\~0.1 - 0.2 mL divided between two cheeks) is placed on the oral mucosa in the buccal cavity for absorption. A sterile cotton swab can be used to gently \"paint\" the inside of the mouth including the tongue, gums, and buccal area, approximately Q 3-4H. How Does Oral Immune Therapy work? As we well know, the immune systems of premature infants are immature and inexperienced. Emerging research is leading us toward OIT as a way to stimulate the development of the neonatal immune system. Premature and low birth weight infants who are unable to feed orally can still receive some of the immunologic benefits of breast milk in a safe and feasible way, with virtually no risk. According to the 2015 position statement from the National Association of Neonatal Nurses (NANN), "as soon as the infant is born and the mother initiates pumping, oral care with human milk can commence." NANN (2015) puts forth three primary rationales for the use human milk for oral care: 1. 2. 3. Furthermore, researchers have recently discovered that OIT may: - - - - - - - Maternal and family participation in human milk oral care was a strong motivator for mothers to keep pumping to build their milk supply for their infant. Probiotics in the NICU Several recent systematic reviews and meta-analyses have concluded that probiotics are safe and effective. Probiotics have been shown to significantly reduce the incidence of NEC and all-cause mortality in preterm infants without an increase in culture-proven sepsis (AlFaleh, 2014; Dickison & Gonzalez-Shalaby, 2022; Yang et al., 2014; Sawh et al., 2016). Other significant findings include shorter duration of hospitalization, increased weight gain, less feeding intolerance and reduced time to reach full enteral feeds, all in favour of using probiotics. Based on this research, probiotic administration is recommended in preterm infants less than 37 weeks gestational age, and less than 2,500 grams. There are still questions regarding the efficacy in extremely low birth weight infants (\ - - - - - - - - Pink, Warm, Sweet, Clean, Organized, and Attached When assessing infants and ensuring that you provide the care that is needed, it is often helpful to have a framework to guide your practice. In the BCIT Neonatal Nursing Specialty, we use the framework of [pink, warm, sweet, clean, organized and attached](https://learn.bcit.ca/content/enforced/1055740-31839.202430/PWSCOA.pdf?ou=1055740). - - - - - - - - - - - Conduction Transfer of body heat to a cooler solid object in contact with the body ---about 5% Convection Flow of heat from body surface to cooler surroundings---about 40% Radiation Transfer of body heat to a cooler solid object not in contact with the body---about 40% - - - - - - - - - - - - - - - - - - - - - - - - - - Late-Preterm Infants: Multi-System Effects Borderline preterm infants can experience all of the multi-system problems facing preterm infants; however, the degree of problems can vary greatly. In this case, Harley is experiencing: - - - He could, particularly if these problems are not appropriately managed, develop more serious problems, including: PDA, persistent pulmonary hypertension of the newborn (PPHN), RDS, cold stress, hypoglycemia, fluid and electrolyte imbalance, hyperbilirubinemia, sepsis, and NEC. IVH is an unlikely complication, given Harley's gestational age. Respiratory Distress Infants who are late-preterm may experience a mild degree of respiratory distress syndrome (RDS). This problem is directly related to their prematurity: lower levels of surfactant, fewer alveoli, fewer capillaries, weak respiratory muscles, and a compliant rib cage. If well managed, this does not usually progress and can be easily managed in the first few days of life. If not well managed, it may progress and the infant will tire and begin to experience the more serious consequences of hypoxia, hypercapnia, and acidosis. RDS in these infants can, in some cases, be serious enough to warrant CPAP or mechanical ventilation. Other respiratory problems Harley could experience are pneumonia and transient tachypnea of the newborn (TTN), also called "wet lung." Thermoregulation Maintaining a neutral thermal environment is one of the key physiologic challenges a newborn infant faces after delivery. While in utero, heat production by the fetus results in a fetal temperature that is approximately half a degree higher than maternal temperature. After birth, the newborn infant is exposed to a much different environment. The risk of hypothermia is real and potentially dangerous and significantly affects both mortality and morbidity. Providing warmth and minimizing heat loss should be an important component of neonatal care. The World Health Organization (WHO) advocates that neonatal body temperature should be maintained at 36.5°C--37.5°C, and it classifies 36.0°C--36.4°C as cold stress or mild hypothermia, 32.0°C--35.9°C as moderate hypothermia, and \ - Humidity is a very important factor in thermoregulation and limiting trans-epidermal water losses in preterm infants. Very preterm infants require the addition of humidity to their isolette in order to prevent heat loss and reduced trans-epidermal water loss. The more premature the infant is, the higher percentage of humidity they require. For example, an infant less that 28 weeks will require 85% humidity initially, while an infant born greater than 32 weeks will not require any additional humidity at all. Infants are generally slowly weaned off humidity to support the maturation of the epidermis and stratum corneum (the outermost layer of the skin). There are several different weaning schedules in the literature; please refer to your unit guidelines when caring for infants who require humidity. An important note about blankets and hats: they are useful for keeping warm infants warm and for warming cool infants in cots. What about for warming cool infants in incubators and on radiant overhead warmers? In these situations, the blankets and hat may only serve to keep the warmth of the incubator and radiant warmer *away* from the infant. For most premature infants, when a parent or other care provider is not available for skin-to-skin, use of an incubator is the most valuable and practical way to manage temperature. In addition to providing warmth, incubators permit observation of breathing, tone and activity, colour, and a variety of other physical assessment parameters. Nursing care aimed at minimizing hypothermia should include: - - - - - - Late-Preterm: Feeding Difficulties Late-preterm infants often experience some degree of feeding difficulty. The feeding problems may range from mild to quite significant. Late-preterm infants may: - - - - - Careful monitoring of feeding patterns, time, and weight is important to ensure that the infant is getting the required amount of nutrition to promote growth and development. Observation and Monitoring The degree of observation and monitoring should be individualized to an infant's condition. In particular, observation and monitoring should be based on a nurse's assessment of an infant's vulnerability. More vulnerable infants may require constant observation and frequent monitoring of vital signs, while less vulnerable infants may only require periodic evaluation, for example, every 3 to 4 hours. Still others may be very stable and require monitoring every 8 to 12 hours. However, any infant who is borderline premature needs to be observed more closely than is routine for full-term healthy newborns. What to monitor is dependent on the individual infant and the cues they are providing. If an infant is experiencing respiratory distress, then respiratory assessment must be frequent and thorough. This may necessitate a radiant warmer or incubator for adequate observation of colour, chest movement, and tone. If thermoregulation is the overriding problem, an incubator may be required. The equipment that is required will also play a part in determining where an infant is best cared for. Depending on the unit that you work in there may be a written protocol for caring for late-preterm infants. These protocols might include pre-printed doctor's orders and assessment and monitoring guidelines. An example of this might be: - - - - - - Fluid Management Fluid and electrolytes are vital components of the body at any age. The estimation of an infant's fluid and nutritional needs depends on the infant's age, weight, and the disease process involved. Please read the following pages from your textbook for more information on fluid and electrolyte management. Fluid Calculations For calculating Harley's fluids, we will use the recommended guideline provided in your text of 80 mL/kg/day. Monitoring his fluid balance will also be done by assessing Harley's weight, urine output, serum sodium, tissue turgor, fontanelles, mucous membranes, and vital signs. The equation is: Step 1: Convert infant's weight from grams to kilograms (1,000 gm = 1 kg). This is because the guidelines and physician's orders are generally in kilograms. Step 2: Multiply the physician's order (or the guideline being used) by the infant's weight. Step 3: Divide by 24 hours in order to get an hourly intake. Caesarean-Section Birth: A Source of Vulnerability The rate of C-section births is increasing worldwide. In Canada, the C-section rate is around 30% (Gu et al., 2019). Of note is the perception that the rate of elective and planned C-sections is increasing at an even higher rate. Many are concerned that, as a culture, we may be losing our wisdom about natural childbirth. But, at the same time, we see significant declines in infant mortality. Could it be that there is a correlation between the rise in C-section births and the fall in infant mortality? Although infant mortality is declining, the rate of TTN increases as more C-sections, particularly those without labour, are performed. Infants born by C-section appear to be less able to clear lung fluid and often take several days to complete the process. During this time, the excess fluid interferes with alveolar expansion and tidal volume diminishes. In order to compensate for the lowered tidal volume and still maintain minute ventilation, the rate of breathing increases, leading to the tachypnea typically seen in these infants. These infants generally require close monitoring and may even need some supplementary oxygen. They may be too tachypneic for nipple feeds (more than 60--70 breaths per minute) and may not even tolerate oral tube feeds, in which case an IV is needed. Once lung fluid has cleared, the tidal volume returns to normal, as does the breathing rate. Feeds can be started and respiratory support discontinued. For many decades, it was believed that the "vaginal squeeze" that occurs during vaginal delivery is what starts lung fluid clearance and that without that squeeze, fluid was retained. Current thinking is that labour is the more important factor and that C-section births without labour create the most significant risk for TTN. During labour, many biohormonal and biochemical changes occur; perhaps one or several of these are responsible for lung fluid clearance. More recently, the gut microbiome has received a considerable amount of attention. A microbiome is the microorganisms in a particular environment, including the human body. Specifically, the gut microbiome is thought to be responsible for many different health factors, including gut and immune system development. When infants are born vaginally, their guts becomes colonized with the beneficial bacteria in the birth canal; when they are born via C-section, this microbiota is altered. Furthermore, women undergoing C-sections usually will receive intrapartum antibiotics, which are thought to pose additional risks in terms of infant microbiota development (Arboleya et al., 2018). Additionally, a C-section birth has the potential to interfere with attachment and breastfeeding. Although there have been many improvements recently, infants born via C-section are often still separated from their mother for a period of time at birth, which can delay skin-to-skin contact and negatively affect attachment and breastfeeding. Substance Use in Pregnancy It is difficult to determine how many women use substances during pregnancy, but it is certain that throughout your neonatal nursing career, you will care for women who have used or are presently using drugs (prescribed and illegal) and/or alcohol. Some of the drugs most often associated with substance use include: - - - - - - - - - - All drugs, whether prescribed or illicit, can be misused and have the potential to cause harm to maternal and/or fetal/neonatal health. Prenatal Exposure to Drugs: Multi-System Effects A variety of drugs or substances may be used during pregnancy. In addition to this, polysubstance use is often a challenge. That is, a mother may be using more than one drug/substance (for example, marijuana, cigarettes, and alcohol) at a time. The challenge with poly-drug use, both from a nursing perspective and a research perspective, is that it is difficult to determine neonatal outcomes due to the overlapping of various substances and their effects. Substance use can affect the developing fetus in three ways: 1. - 2. - 3. - After birth, the newborn can be affected by the following complications: - - - - - - Neonatal Abstinence Syndrome Neonatal abstinence syndrome (NAS) is a group of drug withdrawal symptoms that occur in a newborn who was exposed to opioid drugs during pregnancy. NAS is specific to opioids, but withdrawal can also occur after in-utero exposure to non-opioid agents such as benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and nicotine. Prenatal exposure to cocaine can also cause symptoms of neurologic dysregulation in infants. The Canadian Institute for Health Information reported that approximately 1850 infants per year have NAS, but recent reports suggest that number is increasing and generally under-reported (Lacaze-Masmonteil & O'Flaherty, 2019). Opioid use can be both illicit or prescription and is associated with many adverse pregnancy and infant outcomes, including prematurity, low birth weight, and neurobehavioural abnormalities. The long-term outcomes are difficult to predict due to multiple, interrelated variables of maternal infant risk factors (Lacaze-Masmonteil & O'Flaherty, 2019). Often there are significant other factors, such as poverty, poor nutrition, lack of prenatal care, homelessness, violence, and trauma, that contribute to the vulnerabilities of this patient population. Withdrawal symptoms can appear shortly after birth and up to 2 weeks of age and last for up to 4--6 months (Gardner et al., 2021). Caring for affected infants and families requires a specialized skill set, which we will discuss in detail as you progress through this module. NAS in preterm infants has been reported to be less severe than in full-term infants, but it is very likely that the assessment scales developed for full-term infants are not sensitive enough to identify withdrawal in preterm infants. It is well known that premature infants have much less robust behaviours than full-term infants, so it is not unreasonable to expect signs associated with NAS would also be much more subtle (Maguire et al., 2016). Prenatal Environment: A Source of Vulnerability Maternal antenatal substance use is an environmental factor that greatly increases vulnerability of affected infants like Chelsea, the infant in the case you will be working through in this module. Increased vulnerability arises from the myriad of ways that substances can negatively affect a growing and developing fetus. In addition to antenatal substance use, the environment that Chelsea's mother Desiree is experiencing can also affect the health and welfare of both Desiree and Chelsea. Our health is influenced by many factors, such as the work we do, our level of education, where we live, our gender, and the quality of our early childhood experiences (among others). These factors are called the social determinants of health. Social Determinants of Health Various organizations worldwide, including Health Canada and the World Health Organization, have identified 12 social determinants of health: 1\. Income and social status\ 2. Employment and working conditions\ 3. Education and literacy\ 4. Childhood experiences\ 5. Physical environments\ 6. Social supports and coping skills\ 7. Healthy behaviours\ 8. Access to health services\ 9. Biology and genetic endowment\ 10. Gender\ 11. Culture\ 12. Race/racism (Government of Canada, 2020) In this section, we will not examine each determinant in depth but look in general at the social determinants and try to find the connection to perinatal and neonatal care. Family-Centred and Trauma-Informed Care As you learned in the first theory course, family-centred care is a key concept in neonatal nursing. Family-centred care acknowledges families and communities as part of the social context within which childbearing women live. Through the case of Chelsea and her mother, Desiree, we examine ways that maternal substance abuse increases an infant's vulnerability. This substance abuse also increases a family's vulnerability. Specifically, families in Desiree's situation are at risk for losing custody of their infants or they might have already experienced the abrupt removal of their infant by social services (recent or historical). Women like Desiree face many other barriers when accessing health care, such as fear, guilt, shame, past prejudicial treatment, and negative/harsh attitudes of health care providers. These women often have long histories of trauma, abuse, and violence. A key aspect of providing trauma-informed care is to create an environment where these families do not experience further traumatization or re-traumatization and where they can make decisions about their care in a safe, supportive environment. It is important to note that pregnancy and infancy are recognized as a unique window of opportunity to work preventatively with families. Interventions during this life stage are associated with more positive outcomes, even for the most traumatized families. It is imperative that we care for both the mother and the infant; if we focus on just the infant and don't provide supportive care to the mother, we are essentially ensuring a negative outcome. Meeting the women's needs should be the focal point of the overall plan of care. Trauma-Informed Care What is trauma? - - - - Types of Trauma Trauma is Common - - - - - - - What Is Trauma-Informed Practice? Trauma-informed care recognizes the impact of trauma and provides care to address these complex challenges. Trauma-informed practice includes trauma awareness, offering choice, collaboration and connection, offering safety and trustworthiness, and incorporating strength-based and skill building in our care. More recently, the term "trauma- and violence-informed care" has been used to expand on the concept of trauma-informed care to acknowledge the broader social and structural conditions that impact people's health, including institutional policies and practices. Some examples of trauma and violence-informed care are: - - - - (Varcoe et al., 2016) Harm Reduction Model "Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction is al