This document outlines the management of high risk infants. It defines high risk infants as those exposed to conditions that endanger survival, such as prematurity, low birthweight, or maternal medical conditions. The management of high risk infants requires close observation and individualized care plans. Key aspects of management include prevention of complications, treatment when problems occur, careful advancement of feeding and fluid plans, and addressing the specific needs of special populations like preterm infants and those from multiple births. The overall goal is to identify and address the unique risks faced by each high risk infant.

1. HIGH RISK INFANTS
BY
DR. AYODELE, NOSRULLAH
FMC, BIRNIN KEBBI

2. OUTLINE
 INTRODUCTION
 EPIDEMIOLOGY OF INFANT MORBIDITY AND
MORTALITY
 FACTORS THAT DEFINE AN INFANT AS BEING HIGH
RISK
 SPECIFIC HIGH RISK INFANTS AND MANAGEMENT
 DISCHARGE PROTOCOLS FOR HIGH RISK INFANTS
 COMPLICATIONS
 CONCLUSION
 REFERENCES

3. INTRODUCTION
 The term high-risk infant refers to any baby
exposed to any condition that puts the
survival of the neonate at danger.
 Such babies should be under close observation
by experienced physicians and nurses
 About 10-20% of all births require special or
neonatal intensive care
 Neonatal mortality largely depends on
birthweight and gestational age

4. INTRODUCTION
 For any given duration of gestation, the
lower the birthweight, the higher the
neonatal mortality
 For any given birthweight, the shorter the
gestational duration, the higher the neonatal
mortality
 Most neonatal mortality occurs within the 1st
hours and days after birth
 The highest risk of neonatal and infant
mortality occurs in infants who weigh <1,000
g at birth and whose gestation was <28 wk

5. INTRODUCTION
 The lowest risk of neonatal mortality occurs
in infants with a birthweight of 3,000-4,000 g
and a gestational age of 39-41 wk

6. EPIDEMIOLOGY
 In 2016, 4.2 million (75% of all under-five
deaths) occurred within the first year of life
 The risk of a infant mortality was highest in
the WHO African Region (52/1000 live
births), over 6x higher than that in the WHO
European Region (8/1000 live births).
 Globally, the infant mortality rate has
decreased from an estimated rate of
64.8/1000 live births in 1990 to 30.5/1000
live births in 2016
 In Nigeria, the MICS puts infant mortality
rate at 70/1000 LB in 2017

7. EPIDEMIOLOGY
 Neonatal mortality rates rise sharply for
infants weighing more than 4kg at birth and
for those whose gestational period is 42 wk or
longer.
 The perinatal mortality of twins is about 4
times that of singletons
 Triplet or higher-order births are associated
with an increased risk of death or
neurodevelopmental impairment when
compared with ELBW singleton and twin
infants

8. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
 Demographic social factors
 Maternal age <16 or >40 yr
 Illicit drug - alcohol, cigarette use
 Poverty
 Unmarried
 Emotional or physical stress

9. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
 Past medical history
 Genetic disorders
 Diabetes mellitus
 Hypertension
 Asymptomatic bacteriuria
 Rheumatologic illness (systemic lupus
erythematosus)
 Immune-mediated diseases (immunoglobulin G
crossing placenta)
 Long-term medication

10. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
 History of previous pregnancy
 Intrauterine fetal demise
 Neonatal death
 Prematurity
 Intrauterine growth restriction
 Congenital malformation
 Incompetent cervix
 Blood group sensitization, neonatal jaundice
 Neonatal thrombocytopenia
 Hydrops
 Inborn errors of metabolism

11. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
 Present pregnancy
 Vaginal bleeding
 Sexually transmitted infections
 Multiple gestation
 Preeclampsia
 Premature rupture of membranes
 Short interpregnancy time
 Poly-/oligohydramnios
 Acute medical or surgical illness
 Inadequate prenatal care
 Familial or acquired hypercoagulable states
 Abnormal fetal ultrasonographic findings
 Treatment of infertility

12. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
 Labor and delivery
 Premature labor (<37 wk)
 Postdates pregnancy (≥42 wk)
 Fetal distress
 Breech presentation
 Meconium-stained fluid
 Nuchal cord
 Cesarean section
 Forceps delivery
 Apgar score <4 at 1 min

13. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
 Neonate
 Birthweight <2,500 or >4,000 g
 Birth <37 or ≥42 wk of gestation
 Small or large for gestational age
 Respiratory distress, cyanosis
 Congenital malformation
 Pallor, plethora, petechiae

14. MULTIPLE GESTATION
 Incidence of spontaneous dizygotic twinning
is highest among blacks and East Indians,
followed by northern European whites, and is
lowest in the Asian races
 The incidence of monozygotic twins (3-
5/1,000) is unaffected by racial or familial
factors
 Triplets are estimated to occur in 1 in 86
pregnancies and quadruplets in 1 in 86
pregnancies in the United States (Check
Nigerian data)

15. PROBLEMS OF MULTIPLE
GESTATION
 Polyhydramnios
 Hyperemesis gravidarum
 Preeclampsia
 Premature rupture of membranes
 Vasa previa
 Velamentous insertion of the umbilical cord
 Abnormal presentations (breech)
 Premature labor.

16. PROBLEMS OF MULTIPLE
GESTATION
 Obstruction of the circulation secondary to
intertwining of the umbilical cords
 Respiratory distress syndrome and asphyxia
(second twin)
 Intrauterine growth restriction
 Twin–twin transfusion
 Congenital anomalies

17. MANAGEMENT
 Early detection and anticipation
 Quality antenatal care – adequate caloric
and protein intake, haematinics, iron and
folate supplementation, regular visits, fetal
surveillance / monitoring
 Prevention of preterm labour
 Administration of corticosteroid if preterm
labour is anticipated
 Appropriate labour management
 Management of prematurity
 Management of twin-twin transfusion ( if
present)

18. TWIN-TWIN TRANSFUSION
 Is a rare complication that can occur in
monozygotic monochorionic diamniotic
twins, which causes the blood to pass from
one twin to the other
 Usually occurs due to the presence of
placental vascular communication
 The donor becomes undernourished and
anaemic while the recipient grows normally
and plethoric
 Management more of obstetrics, surviving
infants are managed according to
presentation

20. PRETERM INFANTS
 Term = 37weeks to 42 weeks
 Subdivision by American College of Obstetrics
and Gynecology
 Early term = 37weeks + 0day to 38weeks + 6days
 Full term = 39weeks + 0day to 40weeks + 6days
 Late term = 41weeks + 0day to 41weeks +6days
 Preterm = less than 37weeks
 extremely preterm (less than 28 weeks)
 very preterm (28 to <32 weeks)
 moderate to late preterm (32 to <37 weeks) 2,4

21. PRETERM INFANTS
 Prematurity is the leading cause of death in
children under the age of 5 years 2
 Half of the babies born at or below 32 weeks
(2 months early) die due to a lack of
feasible, cost-effective care, such as
warmth, breastfeeding support, and basic
care for infections and breathing difficulties

22. CAUSES OF PRETERM BIRTH
 Idiopathic
 Induction of labour
 Caesarean section
 Multiple pregnancies
 Infections
 Diabetes mellitus
 Hypertensive diseases in pregnancy
 Extremes of maternal age
 Preterm premature rupture of
membranes

23. CAUSES OF PRETERM BIRTH
 Polyhydramnios
 Antepartum haemorrhage
 Stressful life event
 Uterine/cervical
malformations/abnormalities
 Cervical trauma
 Drug abuse
 Recurrent mid-trimester miscarriage

24.  Hematologic

25. COMPLICATIONS OF PRETERM
BABY
 Hypothermia
 Feeding difficulties
 Breathing difficulties - apnoea
 Pneumonia and early neonatal sepsis
 Intraventricular haemorrhage
 Jaundice
 Retinopathy of prematurity
 Fetal death

26. Williams Obstetrics 23rd edition

27. MANAGEMENT OF PRETERM
INFANTS
 Principles of management 3
 Identification of the clinical problem that the
infant is at risk of developing
 Prevention of the problem
 Identification of problems when they occur
 Early treatment of the problems

28. MANAGEMENT OF PRETERM
INFANTS
 At delivery
 clear the airway
 initiate breathing,
 care for the umbilical cord and eyes,
 administer vitamin K
 Subsequent management
 thermal control
 monitoring of the heart rate and respiration
 oxygen therapy (if indicated)
 fluid management
 nutrition.
 Prevention of infection

29. Thermal control
 Keep thermoneutral environment – provide
warm environment and humidity
 Maintain core temperature at 36.5-37.0°C
 Incubators or radiant warmers can be used
 Alternatives are: Kangaroo mother care with
direct skin-to-skin contact, a hat and blanket
covering the infant

30. FLUID BALANCE
 Very immature preterm infants (<1,000 g) may
lose as much as 2-3 mL/kg/hr
 Larger premature infant (2,000-2,500 g) nursed
in an incubator may have an insensible water
loss of approximately 0.6-0.7 mL/kg/hr.
 VLBW babies are less able to concentrate urine,
so they need higher fluid intake to excrete
solutes
 Adequate fluid intake is essential for excretion
of the urinary solute load (urea, electrolytes,
phosphate).
 Start with 70-80 mL/kg on day 1 and advance
gradually to 150 mL/kg/day.

31. TOTAL PARENTERAL NUTRITION
 The goal is to deliver sufficient calories from
glucose, protein, and lipids to promote
optimal growth
 Indication
 before complete enteral feeding has been established
 when enteral feeding is impossible for prolonged
periods
 Route of administration
 percutaneously
 surgically placed indwelling central venous catheter
 peripheral vein.
 umbilical vein ( for up to 2 wk)

32. TOTAL PARENTERAL NUTRITION
 The infusate should contain
 2.5-3.5 g/dL/day of synthetic amino acids and
 10-15 g/dL/day of glucose,
 2-3g/kg/day of fat emulsion e.g. intralipid 20%
 appropriate quantities of electrolytes, trace
minerals, and vitamins.
 The content of each day’s infusate should be
determined after careful assessment of the
infant’s clinical and biochemical status

33. TOTAL PARENTERAL NUTRITION
 Complications
Complication from catheter Complication from infusate
metabolism
Infection Hyperglycemia
Thrombosis osmotic diuresis
Extravasation of fluid Dehydration
Accidental dislodgment Azotemia
Phlebitis Nephrocalcinosis
Cutaneous sloughing, Hypoglycemia
Hypoxemia
hyperammonemia

34. ENTERAL FEEDING
 Oral feeding (nipple) should not be initiated
or should be discontinued in infants with
 respiratory distress
 hypoxia
 circulatory insufficiency
 excessive secretions
 gagging
 sepsis
 central nervous system depression
 severe immaturity
 signs of serious illness

35. ENTERAL FEEDING
 The main principle in feeding premature infants
is to proceed cautiously and gradually.
 Careful early feeding of breast milk or formula
tends to reduce the risk of hypoglycemia,
dehydration, and hyperbilirubinemia
 Preterm infants at 34 wk of gestation or more
can often be fed by bottle or at the breast.
 Direct breastfeeding may not be successful in
very preterm infants due to poor sucking effort,
so baby may need be fed by bottle or tube

36. ENTERAL FEEDING
 Trophic feeding is the practice of feeding very
small amounts of enteral nourishment to VLBW
preterm infants to stimulate development of
the immature gastrointestinal tract.
 Benefits of trophic feeding include
 enhanced gut motility,
 improved growth,
 decreased need for parenteral nutrition,
 fewer episodes of sepsis,
 shortened hospital

37. ENTERAL FEEDING
 For infants <1 kg, the initial trophic feedings
can be given at 10-20 mL/kg/24 hr as a
continuous nasogastric tube drip (or given by
intermittent gavage every 2-3 hr) for 5-10
days.
 If the initial feedings are tolerated, the
volume is increased by 20-30 mL/kg/24 hr to
a maximum of 150ml/kg/24hr

38. ENTERAL FEEDING
 For infants weighing >1.5 kg , feeding is
initiated at a volume of 20-30 mL/kg/24 hr
 Increase by total daily formula volume of 20-
30 mL/kg/24 hr.
 Indication for review/stoppage of feeding
 regurgitation,
 vomiting,
 abdominal distention,
 gastric residuals from previous feedings (as
indicated by gastric aspiration)

39. ENTERAL FEEDING
 LBW and preterm infants should be given
supplemental vitamins because the volume
of milk sufficient to satisfy daily
requirements may not be ingested for
several weeks

40. PREVENTION OF INFECTION
 Prevention strategies include:
 strict compliance with handwashing and universal
precautions,
 minimizing the risk of catheter contamination and
duration,
 meticulous skin care,
 encouraging early appropriate advancement of
enteral feeding,
 education and feedback to staff,
 surveillance of nosocomial infection rates in the
nursery
 Prophyalctic antibiotics may be given 5

41. POSTTERM INFANTS
 Postterm infants are those born after 42
completed weeks of gestation (from LMP)
regardless of weight at birth.
 Cause is unknown, risk factors include
 Wrong dates
 Maternal factors - primiparity, previous history of
prolonged pregnancy, sedentary habits, genetic
predisposition and elderly multipara.
 Fetal factors - Fetal congenital anomalies such as
anencephaly and adrenal hypoplasia; fetal male
sex
 Placental factors - sulfatase deficiency

42. POSTTERM INFANTS
 Common features of post maturity syndrome
include
 Desquamation of the skin / wrinkling
 long nails,
 abundant hair,
 pale skin,
 alert faces,
 loose skin, especially around the thighs and
buttocks
 meconium-stained nails, skin, vernix, umbilical
cord, and placental membranes

43. POSTTERM INFANTS
 Common complications include
 macrosomia / IUGR
 perinatal depression,
 meconium aspiration,
 persistent pulmonary hypertension,
 hypoglycemia,
 hypocalcemia,
 polycythemia.
 birth injuries
 increased perinatal mortality

44. MANAGEMENT
 Careful obstetric monitoring, including
 nonstress testing,
 Biophysical profile,
 Doppler velocimetry
 Choosing appropriate mode of delivery less
risky for the baby
 nonintervention and subsequent vaginal delivery
 induction of labor, or
 Cesarean section
 Treatment of medical problems in the
newborn if they arise

45. LARGE FOR GESTATIONAL AGE
 Are infants with birthweight > the 90th
percentile for gestational age
 Predisposing factors include:
 Large parental size
 maternal diabetes
 Obesity

46. LARGE FOR GESTATIONAL AGE
 Complications –
 cervical and brachial plexus injuries,
 phrenic nerve damage with paralysis of the
diaphragm,
 fractured clavicles,
 cephalohematomas, subdural hematomas, and
ecchymoses of the head and face.
 hypoglycemia
 polycythemia.
 congenital anomalies

47. MANAGEMENT
 Antenatal detection of at risk infants
 Skilled delivery practices to prevent or
minimize birth injuries
 Management of hypoglycemia and metabolic
problems
 Management of birth injuries

48. INFANT OF DIABETIC MOTHER
 Common complications include
 Fetal macrosomia
 Impaired fetal growth
 Fetal congenital malformation
 Pulmonary disease – RDS, pulmonary hypertension
 Metabolic and electrolyte abnormalities –
hypoglycaemia, hypocalcemia, hypomagnesemia
 Haematological problems – polycythaemia, stroke,
seizure, NEC, renal vein thrombosis
 Cardiovascular abnormalities – VSD, TGA,
cardiomyopathy
 Congenital malformations

49. MANAGEMENT
 Preconception and frequent prenatal
evaluations of all women with diabetes and
pregnant women with gestational diabetes,
 Evaluation of fetal maturity, biophysical
profile, Doppler velocimetry, and planning of
the delivery of these infants in hospitals
where expert obstetric and pediatric care is
continuously available.

50. MANAGEMENT
 Check RBS, serum E/U/Cr
 Infants should initiate feedings within 1 hr
after birth
 A screen glucose test should be performed
within 30 minutes of the first feed
 Treatment is indicated if the plasma glucose
is <40 mg/dL and clinical symptoms of
hypoglycemia are present.
 In asymptomatic infants, treatment is
indicated if the plasma glucose is <30 mg/dl1

51. MANAGEMENT
 A dose of 200 mg/kg of dextrose (2 mL/kg of
10% dextrose) should be administered to
infants with plasma glucose below these
limits.
 If baby cannot tolerate orally, a continuous
peripheral intravenous infusion at a rate of
4-8 mg/kg/min should be given
 Avoid bolus hypertonic glucose, it may cause
further hyperinsulinemia and rebound
hypoglycaemia
 Treat other electrolyte problems accordingly

52. DISCHARGE CRITERIA FOR HIGH
RISK INFANTS
 Growth should be occurring at steady
increments of approximately 30 g/day.
 Temperature should be stabile in an open crib.
 Infants should have had no recent episodes of
apnea or bradycardia
 Parents, or alternative caregivers, who are
willing and able to provide all aspects of the
infant’s care
 Drugs should be oral

53. DISCHARGE CRITERIA FOR HIGH
RISK INFANTS
 Eye test to rule out retinopathy
 Hearing test
 Check Hb to rule out anaemia
 A coordinated plan for outpatient or home
nursing follow-up visits

54. CONCLUSION
 High risk infants require special attention
and optimal care to reduce morbidity and
mortality. Therefore adequate antenatal
care, specialized delivery and early referral
for optimal neonatal care will go a long way
in averting the series of problems associated
with them and help prevent both short term
and long term complications.

55. REFERENCES
1. Kliegman, Robert, Richard E. Behrman, and Waldo E.
Nelson. Nelson textbook of pediatrics. 20th edition.
2016.
2. World Health Organization - Preterm birth fact
sheets. Available at
http://www.who.int/mediacentre/factsheets/fs363
/en/
3. Howson CP, Kinney MV, Lawn JE. Born too soon: the
global action report on preterm birth. Geneva:
World Health Organization. 2012 May:1-126
4. Azubuike JC, Nkanginieme KE. Paediatrics and child
health in a tropical region. 2nd edition. African
Educational Services. 2007

56. REFERENCES
5. Saxena R. Bedside Obstetrics & Gynecology. JP
Medical Ltd; 2014
6. Medscape: Infant of diabetic mother. Available at:
https://emedicine.medscape.com/article/974230-
overview#a2
7. Multiple Indicator Cluster Survey. Nigeria Survey
Finding Report, 2016-2017
8. Cunningham F, Leveno K, Bloom S, Hauth J, Rouse D,
Spong C. Williams Obstetrics 23rd Edition McGraw
Hill. New York. 2010