High risk infant

1. HIGH RISK NEWBORN
Soumya Ranjan Parida

4. INTRODUCTION
A newborn, regardless of gestational age or birth
weight, who has a greater than average chance of
morbidity or mortality because of conditions or
circumstances superimposed on the normal course of
events associated with birth and the adjustment to
extra uterine existence.
IAP Teaching Slides 2015-2016

5. FACTORS –TO DEFINE HIGH RISK INFANT
• A) Demographic social factors
• B) Past medical history
• C) Previous pregnancy
• D) Present Pregnancy
• E)Labor and delivery
• F)Neonate

6. Demographic social factors
• Maternal age <16 or >40yr
• Poverty
• Unmarried
• Emotional or physical stress
• Illicit drug, alcohol, cigarette use

7. B) Past medical history
• Genetic disorders
• Diabetes mellitus
• Hypertension
• Asymptomatic bacteriuria
• Rheumatologic illness
• Immune –mediated disease
• Long-term medication

8. C) Previous pregnancy
• Intrauterine fetal demise
• Neonatal death
• Prematurity
• Intrauterine growth restriction
• Congenital malformation
• Incompetent cervix
• Blood group sensitization
• Neonatal thrombocytopenia
• Hydrops fetalis
• IEM

9. D) Present Pregnancy
• Vaginal bleeding
• Sexually transmitted infections
• Multiple gestation
• Preeclampsia
• PROM
• Short interpregnancy time
• Poly-/ oligohydramnios
• Acute medical or surgical illness
• Inadequate prenatal care
• Familial or acquired hypercoagulable states
• Abnormal fetal USG findings
• Treatment of infertility

10. E)Labor: and delivery
• Premature labor (<37wk)
• Postdates pregnancy(≥42wk)
• Fetal distress
• Immature lecithin: spingomylin ratio; absence of
phosphatidyleglycerol
• Breech presentation
• Meconium –stained fluid
• Nuchal cord
• Cesarean section
• Forceps delivery
• Apgar score <4 at 1 min

11. F)Neonate:
• Birth weight ≤2500 or ≥4000g
• Birth <37 or ≥42wk of gestation
• Small or large for gestational age
• Respiratory distress, cyanosis
• Congenital malformation
• Pallor, plethora, petechiae

13. DEFINITION
• Low Birth Weight Infant:
• Live born baby weighing 2500 gram or less at birth.
• (VLBW: <1500 gm, ELBW:<1000 gm). ‐
• Preterm:
• When the infant is born before term. i.e.: before 38
weeks of gestation.
• Premature:
When the infant is born before 37 weeks of gestation

14. DEFINITION
• Full term:
When the infant is born between 38 – 42
weeks of gestation.
• Post term:
When the infant is born after 42 weeks of
gestation.

15. POST TERM NEWBORN CHARACTERISTICS
 Newborn emaciated ▪ dry peeling skin
 Meconium stained ▪ Creases cover soles
 Hair and nails long ▪ Limited vernix & lanugo

16. Low Birth Weight Newborn:
● Preterm ● IUGR
Term
pretermSymmetric
A Symmetric

17. Major problems in preterm babies and those
with IUGR
Preterm IUGR
Hypothermia Perinatal asphyxia
Perinatal asphyxia Meconium aspiration
Respiratory Hypothermia
Bacterial sepsis Hypoglycemia
Apnea of prematurity Feed intolerance
Metabolic Polycythemia
Hematologic Poor wt gain
feeding problems
and Poor wt gain

18. Management
• Prepare for high risk of need for resucsitation
• Gentle resucsitation using small bags for PPV ,use of
CPAP
• Take extra care to avoid hypothermia
• Special attention to maintenance of warm chain
• KMC
• Strict adherence to asepsis, hand hygiene
• Management of metabolic, hematologic abnormality
Management of immature organ systems in preterm

19. Choosing initial methods of feeding
>34 weeks
Initiate breast feeding
Observe if, positioning &
Attachment are good, able to suck
Effectivly and long enough (10-15min)
yes
Breast feeding
Start feeds by spoon
Or paladai
no
Observe if accepting well
Without spilling/coughing
Yes,spoon/
Paladai feeding
No, start feeds by OG or NG tube
No vomiting/abd distension
Gastric tube feeding
32-34weeks
28-31 weeks
<28wks
Vomiting/abd distension
Start IV fluid

20. Progression of oral feeding in preterm LBW neonates
Infant on IV fluids
Start trophic feeding by OGT
And monitor for feed intolerence
If accepting well
Gradually increase the feed volume
Taper & stop IV fluids
Newborn with OGT feeds
Try spoon feeds once or twice a day
Put on mother’s breast and allow non nutritive
suck
Gradually ↑ the frequency & amount
↓OGT feeds
Put the baby on mother’s breast before each
feed,if good attachment and effective suckin
Taper and stop spoon feeds
Once the mother is confident

21. Nutritional supplements for infants with birth wt
between 1500-2499g
Nutrition Method of
supplementation
Dose Duration
Vitamin D Multivitamin drops 400IU/day 2wks to 1yr
Iron Iron drops 2mg/kg/day 6-8wks to 1yr

22. Supplementation in VLBW neonates
1) Calcium & phosphorus (140-160mg/kg /D & 70-
80mg/kg/D for infants on EBM)
2) Vitamin D ,B complex,Zinc
3) Folate (50 µg/kg/D)
4) Iron
Supplementation should be added at different times in the
day to avoid abnormal ↑ in osmolality

23. Management of inadequate wt gain
• Proper counselling of mothers,assessment of
positioning/attachment & managing sore ,flat nipple
• Frequency & timing of both breast feeding and
spoon or paladai feeding
• EBM by spoon or paladai feeding (preterm)
• Initiating fortification of breast milk when indicated

26. INFANT OF DIABETIC MOTHER

27. PATHOPHYSIOLOGY
•
Maternal hyperglycemia
Fetal hyperglycemia in‐utero
Fetal hyperinsulinemia‐ increased fat and
glycogen synthesis‐ Macrosomic infant
cord clamped
Interrupts the transplacental glucose supply
Inspite of which Hyperinsulinemia persists,
this leads to hypoglycemia

28. DISORDERS IN INFANTS OF DIABETIC MOTHERS
• Hypoglycemia.
• Hypocalcimia.
• Hypomagnesemia.
• Cardio‐respiratory disorders
• Hyperbilirubinemia (Unconjugated)
• Birth injuries
• Congenital malformations

29. MANAGEMENT:
For the mother:
Good antenatal care for proper control of maternal
Diabetes
For an infant:
All IDMs should receive continuous observation and
intensive care. Serum glucose levels should be
checked at birth and at half an hour, 1, 2, 4, 8, 12, 24,
36 and 48 hours of age:

30. MANAGEMENT:
• If clinically well and normoglycemia; oral or gavage
feeding should be started and continued within 2 hours
intervals.
• If hypoglycemic; give 2 – 4 ml/kg of 10% dextrose over
5 minutes, repeated as needed.
• A continuous infusion of 10% glucose at a rate of 8‐10
mg/kg/min. Start enteral feeding as soon as possible.
Give Corticosteroids in persistent hypoglycemia.
• Oxygen therapy for RDS, Calcium gluconate 10% for
hypocalcemia, phototherapy for hyperbilirubinemia

31. MANAGEMENT OF THE NEONATE AT RISK:
Prevention
• First of all, providing a warm environment.
• Early enteral feeding is the single most
important
Preventive measure
If enteral feeding is to be started, if the infant
is able to tolerate nipple or nasogastric tube
feeding.

32. FOLLOW UP OF HIGH RISK INFANT

33. PRE DISCHARGE
• Active surveillance
– Medical examination
– Neurobehavioral and Neurological examination
– Neuroimaging
– ROP screening
– Hearing screening
– Screening for congenital hypothyroidism
– Screening for metabolic disorders

34. CATEGORIZE‐ FOR FOLLOW UP
• High Risk:
– Babies with <1000g birth weight and/or gestation
<28 weeks
– Major morbidities such as chronic lung disease,
intraventricular hemorrhage and periventricular
leucomalacia
– Perinatal asphyxia ‐ Apgar score 3 or less at 5 min
and/or hypoxic ischemic encephalopathy
– Surgical conditions like Diaphragmatic hernia,
Tracheoesophageal fistula
-- Small for date (<3rdcentile) and large for date (>97th centile)
– Mechanical ventilation for more than 24 hours

35. CATEGORIZE‐ FOR FOLLOW UP
• Persistent prolonged hypoglycemia and
hypocalcemia
• Seizures, meningitis
• Shock requiring inotropic/vasopressor support
• Infants born to HIV‐positive mothers
• Twin to twin transfusion
• Neonatal bilirubin encephalopathy
• Inborn errors of metabolism / other genetic disorders
• Abnormal neurological examination at discharge

36. MODERATE RISK:
• Babies with weight – 1000 g‐ 1500g or gestation <33
weeks
• Twins/triplets
• Moderate Neonatal HIE
• Hypoglycemia, Blood sugar<25 mg/dl
• Neonatal sepsis
• Hyperbilirubinemia > 20mg/dL or requirement of
exchange transfusion
• IVH grade 2
• Suboptimal home environment

37. MILD RISK
– Preterm,
– Weight 1500 g ‐ 2500g
– HIE grade I
– Transient hypoglycemia
– Suspect sepsis
– Neonatal jaundice needing PT
– IVH grade 1

38. FOLLOW UP
• Low risk:
• Follow up with pediatrician / primary care
• provider with objective to screen for
• deviation in growth and development.
• Moderate risk:
• Follow up with neonatologist and developmental pediatrician:
• screen for developmental delay, manage intercurrent illnesses
• with
• – Developmental pediatrician ,
• – Radiologist, Audiologist, Ophthalmologist
• – Social worker, Dietician, Physiotherapist

39. FOLLOW UP
• High risk babies
• Neurodevelopmental delay: supervise & screen
for developmental delay with Neonatologist and
with
Team as for Moderate risk and
• – Pediatric neurologist
• – Geneticist
• – Occupational therapist
• – Speech therapist
• – Endocrinologist
• – Pediatric surgeon

40. Take home message
• All new born are precious
• Extra effort, extra care
• Communication through warm lines
• Early referral
• prevention