Newborns

Care for minor problems and transitional issues (jaundice, hypothermia)

Care of preterm infants ≥ 32 wks GA

Conditions that will resolve rapidly (sepsis, mild RDS)

Care of severely preterm infants

Usually have long term problems

"Teritary" centers

Specialty care

• Respiration
• Thermoregulation
• Nutrition
• F&E balance
• Skin
• Infection
• Pain

• Birth weight
• Gestational age
• Pathophysiologic problems

• Low birth weight babies
• Weight below the 10% normal weight for it's GA (different weights for different GAs)

Indicates long-term complications

Total # of cells are decreased

Caused by congenital anomalies, exposure to infection or drugs early in pregnancy

Head looks big in comparison to body

Brain and heart size are normal, other organs may be small

Usually has loose skin and loss of SQ fat

Growth issue starts in 3^rd trimester

Generally "catch up" in size

• Multi-gestation
• Substance abuse
• Smoking
• Age extremes
• Lack of prenatal care
• Low socioeconomic status
• Diseases: PIH, heart disease, substance abuse, sickle cell, DM

• High altitude
• Exposure to x-rays
• Smoke (second-hand or first-hand), alcohol
• Excessive exercise
• Exposure to toxins
• Hyperthermia

• Small placenta
• Placenta previa
• Abnormal cord insertion
• Congenital infection
• Chromosomal abnormalities
• Discordant twins
• Malformations

• Assess for hypoglycemia (d/t small liver & inadequate glycogen stores)
• Feedings--early and more frequent
• Assess for hypothermia
• Extra clothes and blankets
• Overhead warming units
• Isolettes

Infant whose birth weight is at or above the 90^th % at any week of gestation

Most commonly infants born to Diabetic moms

• Birth trauma and increased chance of c-section
• Hypoglycemia
• Polycythemia & hyperviscosity
• Respiratory distress syndrome
• Congenital birth defects
• Acquired birth defects (shoulder dystocia, brachial palsy, facial paralysis/nerve palsy)

• Most noticable when baby cries
• Paralyzed on affected side of face (from forehead to chin if severe)
• Eyelid may not close on affected side
• During crying:
• Lower face (below eyes) appears uneven 
• Mouth doesn't move down same way on both sides

• Brachial plexus nerves
• Fractured clavicles
• Fractured humeri
• Contusions and lacerations
• Birth asphyxia

• Caused by shoulder dystocia
• Damaged sternocleidomastoid muscle--> head pulled down and to one side
• Erb's palsy on affected side
• Limited movement of arm
• Absence of moro reflex on affected side

• Assess for birth injuries
• Fractured clavicles, brachial palsy
• Assess for hypoglycemia
• Follow hospital protocol for obtaining BG by heel stick
• Assess respiratory functioning
• Rate, effort, breath sounds

An infant born past 42 weeks

12% of all pregnancies

• Caused by decreased placental functioning--> low O₂ levels and nutrition transport
• Occurs in 5% of post-term infants

• Hypoxia
• Malnourished
• Loose skin
• Long nails
• Wrinkled, crackled, and peeling skin
• Meconium-stained cord

• Assess respiratory functioning
• Assess for hypoglycemia (early & frequent feedings)
• Assess for hypothermia (blankets, warming units, etc.)
• Assess for polycythemia (increases risk for hyperbilirubinemia)
• Parent teaching:
• Feedings, S/S of hypoglycemia, supplementing if needed

Birth weight 1000-1500 g = 85-90% chance 

Birth weight 500-600 g = 20% chance

• Exact cause is unknown !!
• Infection
• Multi-gestation
• Hx of previous preterm delivery
• Maternal disease (PIH, DM, heart disease)
• Substance abuse
• Extreme age (<17 or >35)
• Low socioeconomic status

• Adequate prenatal care
• ID high risk moms
• ID and treat infections early
• Teach mom s/s of preterm labor
• Adequate nutritional state of mom
• Early ID of substance abuse

Tachypnea caused by retained lung fluid

Self-limiting

Treatment is supportive

• C-section
• Asphyxia at birth
• Maternal analgesia
• Bleeding
• Diabetes

• Tachypnea (as high as 120/min)
• Retractions
• Nasal flaring
• Possible grunting
• Mild cyanosis
• Streaking/ fluid seen in chest x-ray

• Develops when meconium in the amniotic fluid enters the lungs during fetal life or at birth
• Meconium in lungs--> obstruction of airways and air trapping--> pneumothorax and/or respiratory distress
• Risk factors: stressed infant !

(see chart slide 26 for visual) 

• Clear airway at birth (initial suction by OB then deep suctioning through intubator by NICU team)
• Respiratory support (O₂, ventilation)
• Antibiotics
• Possible ECMO (extracorporeal membrane oxygenation)

• Insufficient production of surfactant--> alveoli collapse with each exhale--> lungs become stiff and resist expansion
• Long term, can lead to bronchopulmonary dysplasia (BPD)

• Grunting on expiration
• Tachypnea
• Retractions
• Cyanosis
• Nasal flaring
• Respiratory acidosis

• Supportive !
• Mechanical ventilation
• Surfactant replacement with Survanta
• Can be repeated several times
• Higher survival rates and fewer complications !

• Constant observation of glucose levels and ABGs
• Periodic vs. apneic breathing 
• Watch for retractions and grunting

• Reduce inappropriate stimuli
• Positioning/ reposition
• Kangaroo care
• Hydration maintenance
• Suctioning

• Vertical transmission-- in utero
• Across the placenta
• During labor (in the birth canal)
• Horizontal transmission-- after birth
• Hospital staff or equipment (nosocomial)
• Family members

• Group B strep
• E. coli
• Haemophilus influenzae
• Staph aureaus
• Syphillis, gonorrhea
• Toxoplasmosis
• Viral (CMV, herpes, HIV, rubella)

• Temperature instability (usually with low, not high)
• Respiratory problems
• Feeding intolerance
• Lethargy
• Hypoglycemia
• Apnea

• Testing: blood cultures, urine samples, CBC, CSF, C-reactive protein
• Broad-spectrum antibiotics (ampicillin or gentamicin usually)
• Supportive care:
• Fluids, O₂, warmth, glucose stabilization

• No extra fat
• Smaller stomachs
• Need 105-130 kcal/kg/day
• GI doesn't absorb fat well
• Is baby absorbing feedings ?
• Aspiration
• Regurgitation
• Diarrhea

• Watch for S/S of intestinal complications
• Parenteral feedings
• Gavage (via nose/ mouth)
• Oral feeding
• Begin at 32-34 wks GA
• Breastfeeding moms of preterm infants: milk storage

• Infection and inflammation that causes destrction of the bowel or part of the bowel
• Most common and serious GI disorder in preterm infants !

• May need to do resection (remove bad part surgically), possible ostomy
• NPO with parenternal nutrition
• NG tube to suction
• Antibiotics
• Check stools for blood
• Monitor CBC and electrolytes
• Abdominal girths q2h and RBC transfusion (as ordered)

• Unstable temperature
• Bloody stools
• Poor feeding
• Feeding intolerance
• Bile-colored, or gree, gastric residuals or vomiting

• Bleeding into the fluid-filled areas (ventricles) inside the brain
• Most often infants <32 wks GA, usually during first few days of life
• Smaller and earlier the infant = higher the risk for IVH
• Organized by grades 1-4

• May lead to lifelong blindness or vision impairment
• Usually infants <1500 g or <32 wks GA
• Smaller babies are more likely to develop ROP
• Etiology RT delivering high levels of O2 under pressure = proliferation of fragile blood vessels
• Important to monitor O2 sats !

• Red flags:
• Lack of prenatal care
• Placental abruption
• Behavior of mom
• Maternal drug test can only be done with consent !!
• Infant drug test can be done without parental consent !
• Positive drug test = CPS referral

• Irritable, jittery, restless
• Prolonged high-pitched cry
• Tachypnea
• Seizures
• Difficult to console
• Poor feeding, vomiting, diarrhea
• Poor sleep patterns
• Sneezing, nasal stuffiness

• Decrease stimulation (cluster care, keep lights low)
• Swaddle
• Find a quiet spot in nursery or NICU
• Watch for signs of withdrawal and notify pediatrician

• Most common hemolytic disorder
• When fetus is type A, B, or AB and mom is type O
• Anti-A and anti-B antibodies are transferred across placenta to the fetus
• Exchange transfusions are required occassionally
• Usually not severe

• When Rh- moms have an Rh+ fetus
• Mom forms antibodies against fetal RBCs
• Once the antibodies are formed, any future Rh+ pregnancies will likely result in miscarriage 
• RhoGam is administered in these situations to prevent formation of antibodies

• Given at 28 wks and w/in 72 hrs PP
• Prevents sensitization of mom to Rh+ blood
• Once sensitized, always sensitized ! (can't reverse)
• RhoGam destroys RBCs from the baby that have entered mom's blood stream preventing formation of antibodies to Rh factor

• S/S of pain:
• Increased ICP during procedures (only measured in NBs w/intraventricular hemorrhage, via MD order)
• Behavioral changes-- cry face, grimace
• Physiologic changes-- decreased O2 levels
• Care:
• Prepare the infant
• Administer pain meds

• Encourage photographs
• Name card
• Teaching parents on bonding
• Involve parents in decision making
• Kangaroo care (skin to skin)

• Sources of stimulation:
• Bright lights, noise, tests, treatments
• Avoiding stress:
• Schedule disruptions (cluster care)
• Reduce noise
• Build a nest for rest (w/ blankets and pillows)
• Maintain flexion
• Inform others to not disrupt

• Premature infants with:
• RDS
• Unstable BP
• Other medical conditions at birth

• Grades 1 and 2:
• Less bleeding
• Often causes no long terms problems
• Grades 3 and 4:
• Severe bleeding
• Blood presses on or leaks into brain tissue
• Blood clots may block flow of CSF and cause hydrocephalus

• Breathing pauses (apnea)
• Changes in BP and HR
• Decreased muscle tone
• Decreased reflexes
• Excessive sleep
• Lethargy
• Weak suck
• Seizures and other abnormal movements

• Cannot stop bleeding
• Treat symptomatically to keep infant stable
• ex: blood transfusion may be given to improve BP