This document discusses high risk neonates and infants, including those born preterm or post-term, small or large for gestational age, or with congenital anomalies. It describes common conditions in these populations like respiratory distress, hypoglycemia, intraventricular hemorrhage, and necrotizing entercolitis. For each condition, risk factors, signs, and interventions are outlined. Congenital anomalies discussed include diaphragmatic hernia, tracheo-esophageal fistula, and neurotube defects. The needs of infants of diabetic or substance abusing mothers are also reviewed.

1. High Risk Neonates and
Infants


2. Who Is an At-Risk Infant?
 Risk of morbidity or mortality
 Prenatal and intrapartal risk factors
 Neonatal factors
 Gestational age
 Size
 Anticipate complications
 Assessments at birth - Apgar score

3. High Risk Infant
 Congenital anomalies
 Characteristics and potential problems
 Preterm & postterm
 Small for gestational age & large for gestational age
 General concerns
 Thermoregulation
 Hypoglycemia
 Respiratory distress and complications
 Hyperbilirubinemia
 Psychosocial neonate & family needs

4. Congenital Anomalies
Diaphragmatic Hernia
 Abdominal contents herniate through diaphragm
 Respirations are compromised
 Signs
 Barrel shape chest
 Asymmetric chest expansion and absent
breath sounds on affected side
 Respiratory distress and cyanosis
 Scaphoid abdomen

5. Congenital Anomalies:
Diaphragmatic Hernia
 Interventions
 Oxygen
 Respiratory support without over inflating
 Gastric decompression
 Head of bed elevated
 Turn to affected side
 Surgical repair

6. Congenital Anomalies:
Tracheo-Esophageal Fistula
 Connection between the trachea and esophagus
 Proximal esophagus ends in blind pouch and
distal esophagus joined to trachea
 Signs
 Increased oral secretions
 Coughs and choking
 Abdominal distention
 Not able to pass nasal or oral gastric tube
 Struggles with feeding

7. Congenital Anomalies:
Tracheo-Esophageal Fistula
 Interventions
 Withhold feedings
 Elevate head of bed
 Suction to blind pouch to decrease
aspiration
 Surgery

8. Congenital Anomalies:
Neurotubular Defects
 Tissue protruding through vertebral column
 Meningocele
 Meningomyelocele
 Impairment
 Location and magnitude of defect determines
extent of neuro impairment
 Sensory impairment follows motor, affects
bladder and anal sphincter, contractures and
deformities

9. Congenital Anomalies:
Neurotubular Defects
 Intervention
 Pregnancy -- Folic acid and Alpha fetal protein
 Sterile, moist, normal saline dressing
 Prevent infection
 Decrease trauma
 Monitor for changes in fluid and heat loss
 Surgical repair, keep prone with legs flexed,
no diaper over incision
 Long term: hydrocephalus, wheelchair,
braces, catheterization

10. Congenital Anomalies:
Gastrocele and Omphalocele
 Gastroschisis
 Abdominal contents protrude through wall
 No sac covering intestines
 Omphalocele
 Abdominal contents protrude into umbilical cord
 Covered by translucent sac
 Associated with other anomalies

11. Congenital Anomalies:
Gastrocele and Omphalocele
 Interventions
 Warm, moist, sterile dressing and plastic
wrap
 Maintain hydration and temperature
 Position supine or side
 Gastric decompression
 Surgical repair
 Complications

12. Congenital Anomalies:
Choanal Atresia
 Occlusion at nasopharnyx
 Signs
 Snorting respirations
 Difficulty breathing with feedings
 Cyanosis
 Interventions
 Assess patency of nares
 Maintain airway with oral airway
 Position with head of bed elevated

13. Congenital Anomalies:
Cleft Lip and Palate
 Fissure involving nares, nasal septum, or
connecting oral and nasal cavity
 Intervention
 Feedings with special nipples
 Feed upright and burp frequently
 Prevent aspiration
 Clean mouth after feedings

14. Congenital Anomalies:
Heart Defects
 Signs
 Cyanosis
 Heart murmur
 Heart failure
 Most common defects
 Patent ductus arteriosus
 Ventricular septal defect- most common in Children
 Coarctation of the aorta
 Hypoplastic left heart
 Tetralogy of Fallot
 Transposition of the great vessels

15. Substance-abusing Mother:
Fetal Alcohol Syndrome
 Facial abnormalities
 Behaviors
 Difficulty establishing respirations
 Sleeplessness - Jittery
 Hyperalert states - Hyper reflexes
 Inconsolable crying - Poor sucking
 Irritability - Lethargy

16. Substance-abusing Mother:
Fetal Alcohol Syndrome
 Long-term complications
 Hypotonic and poor coordination
 Mental retardation or normal intelligence
 Speech and learning disabilities
 Hyperactivity and impulsivity
 Growth retardation
 Intervention
 Treat respiratory distress
 Reduce environmental stimulation
 Extra feeding time

17. Substance-abusing Mother:
Drug Dependence
 Pregnant woman increased risk of
 Abruptio placentae, abortion, preterm
labor, precipitous labor
 Neonate increased risk of
 Intrauterine asphyxia
 Respiratory problems
 Urogenital malformation
 Cerebrovascular complications
 Low birth weight and head circumference
 Drug withdrawal

18. Substance-abusing Mother:
Drug Dependence
 Key assessment findings
 Tachypnea - Sensitive to stimuli
 High-pitched cry - Low birth weight
 Jitteriness - Hyperactive Moro reflex
 Poor sleeping - Increased reflexes
 Irritability - Diarrhea & vomiting
 Interventions
 Swaddling - Calm environment
 Frequent feeding - Medication
 Promote bonding

19. Inborn Error of Metabolism:
Phenyleketonuria (PKU)
 Condition affects protein metabolism
 No enzyme to convert phenylalanine to
tyrosine
 Affects development of brain and CNS
 Mental retardation if untreated
 CNS damage minimized if treatment before
age 3 months

20. Inborn Error of Metabolism:
Phenyleketonuria (PKU)
 Assessment
 Positive Guthrie test – 24 hrs after feedings
 Failure to thrive - Microcephaly
 Vomiting - Hyperactivity
 Skin lesions - Irritability
 Repetitive motions
 Seizures and tremors
 Musty odor from skin and urine
 Intervention
 Low-phenylalanine formula
 Teach parents allowed foods in the diet

21. Inborn Error of Metabolism:
Congenital Hypothyroidism
 Enzymatic defect, lack of idodine in maternal
diet, or maternal drugs can depress thyroid
tissue
 Causes growth and mental retardation
 Assessment
 Large tongue = Prolonged jaundice
 Umbilical hernia = Poor feeding
 Mottled skin = Low-pitch cry
 Large fontanelles = Poor weight gain
 Hypotonia = Delayed development
 Intervention: Monitor thyroid medication

22. Identification of At-Risk Newborns
 Gestational age
 Preterm
 Post-term
 Size of neonate
 Small for gestational age
 Large for gestational age

23. Large for Gestational Age
 Birth weight at or above the 90th percentile
 Etiology
 Large parents
 Multiparous women
 Males larger than female
 Assessment findings
 Poor muscle tone and motor skills
 Difficult to arouse and maintain an alert state

24. Large for Gestational Age
 Complications
 Birth trauma – ceohalopelvic disproportion
 Asphyxia
 Meconium aspiration
 Polycythemia
 Hypoglycemia

25. Infant of Diabetic Mother
 Severe diabetes associated with vascular
complications may have small babies
 Mothers with classes A and C may have LGA
 High glucose stimulates fetal insulin increase
 Complications
 Hypoglycemia
 Hypocalcemia
 Hyperbilirubinemia
 Birth trauma

26. Infant of a Diabetic Mother
 Complications
 Polycythemia
 Respiratory distress syndrome
 Congenital birth defects
 Interventions
 Test blood glucose
 Cord blood; q hr X 4; q 4hr for 24 hrs
 If blood glucose is < 40 mg/dl
 Feeding
 IV fluid of 10% dextrose water

27. Small for Gestational Age
 Birth weight at or below the 10th percentile
 Intrauterine growth retardation
 Deficiency of nutrients through the placenta
 Poor nutrition
 Smoking or drug use
 Pregnancy induced hypertension
 Advanced diabetes
 Intrauterine infection

28. Small for Gestational Age
 Physical characteristics
 Decreased subcutaneous tissue
 Loose skin
 Thin/dry umbilical cord
 Alert for size
 Dubowitz changes
 Problems
 Hypothermia
 Hypoglycemia
 Asphyxia
 Meconium aspiration

29. Small for Gestational Age
 Problems
 Hypocalcemia
 Feeding difficulties
 Polycythemia
 Interventions
 Support respirations
 Provide neutral thermal environment
 Provide appropriate nutrition and hydration
 Monitor blood glucose levels
 Cluster care
 Provide skin care

30. Post-term Infant
 Infant born after 42 weeks gestation
 Most continue to be well nourished
 Postmaturity syndrome
 Calcium deposits decrease placenta
function
 Results in lack of oxygen and nutrients
 Physical characteristics
 Absent vernix and decreased lanugo
 Dry, cracked, parchment-like skin, peeling
 Hard, long nails
 Abundant scalp hair

31. Post-term Infant
 Physical characteristics
 Loose skin
 Decreased subcutaneous fat
 Problems
 Hypothermia
 Hypoglycemia
 Asphyxia
 Meconium aspiration
 Polycythemia
 Interventions
 Supportive

32. Premature Infant
 Born before the 37th week gestation
 Physical characteristics
 Skin is thin, smooth, shiny, with visible veins
 Minimal subcuatneous fat deposits
 Lanugo over body
 Minimal sole and palm creases
 Large head
 Ears have soft cartilage
 Genitals
 Posture is extended
 Reflexes absent or weak -- suck, gag

33. Premature Infant
 Problems
 Hypothermia
 Hypoglycemia
 Respiratory distress syndrome
 Apnea and bradycardia
 Patent ductus arteriosus
 Hyperbilirubinemia
 Anemia
 Intraventricular hemorrhage
 Retinopathy of prematurity
 Necrotizing entercolitis

34. Apnea & Bradycardia
 Bradycardia: heart rate less than 100 bpm
 Apnea: not breathing for > 15 to20 seconds
 Causes of apnea
 Obstructed airway
 Hypothermia or hyperthermia
 Hypoglycemia
 Sepsis
 Respiratory distress

35. Apnea and Bradycardia
 Causes of apnea
 Anemia
 Hypercapnea
 Sepsis
 Hypocalcemia
 Seizure
 Vagal response
 Dehydration
 CNS depression
 Intraventricular hemorrhage

36. Apnea and Bradycardia
 Interventions
 Tactile stimulation
 Suction airway
 Provide oxygen
 Provide mechanical ventilation
 Correct underlying cause
 Administer CNS stimulants
 Caffeine or theophylline

37. Intraventricular hemorrhage
 Hemorrhage in the ventricles of the brain
 May cause motor deficits
 Hydrocephalus
 Sight and hearing loss
 Causes
 Capillary walls vulnerable to hypoxic events
 Hypoxia & high CO2 dilates cerebral vessels
 Changes in intravascular pressure

38. Intraventricular hemorrhage
 Signs
 May be no signs
 Bulging fontanel
 Signs of intracranial pressure
 Interventions
 Keep cerebral blood flow constant
 Prevent hypoxia
 Prevent increased blood pressure
 Elevate head of bed

39. Anemia
 Causes
 Iron stored late
 Short life of RBC
 Blood drawing
 Hemorrhage
 Interventions
 Transfuse Packed red blood cells
 Iron suppliments and erythopoientin
 Signs
 Pallor
 Tachypnea
 Dyspnea
 Tachycardia
 Activity intolerance
 Feeding difficulty

40. Retinopathy of Prematurity
 Progressive disorder of retina vessels
 Scar tissue and retina detachment
 Causes
 Fragile retinal vessels
 Fluctuating oxygen administration levels
lead to rapid vasodilation and
vasoconstriction
 Also occurs with hypoxemia,
intraventricular hemorrhage, infection,
acidosis, exposure to bright lights

41. Retinopathy of Prematurity
 Interventions
 Decrease intracranial pressure
 Careful O2 administration
 Decrease lighting in NICU
 Eye exams
 May regress spontaneously
 Laser/cryosurgery
 Vitamin E

42. Necrotizing entercolitis
 Cause
 Bowel eschemia during hypoxia
 Gas forming bacteria invade damaged cells
of intestinal wall
 Cells rupture causing air in surface of
bowel
 Damages bowel wall and causes bleeding
 Milk in bowel provides rich media for
bacteria growth

43. Necrotizing entercolitis
 Abdominal signs
 Pneumotosis in bowel wall
 Free air in abdomen if perforated
 Distended and shiny abdomen
 Gastric retention
 Blood in stools
 No bowel sounds
 Signs of sepsis

44. Necrotizing entercolitis
 Interventions
 NPO
 Nasal gastric tube for decompression
 X-rays to follow deterioration of bowel
 Antibiotics
 Surgery – resection of damaged portion
 Monitor for abdomen distension
 Hematest stools
 Long-term IV therapy
 Decrease O2 consumption

45. Nutrition for the Preterm
 Inability to nipple feed until 35-36 wks
 Gag reflex
 Suck/swallow/breathe coordination
 Tires easily and worsens respiratory distress
 Require different composition of formula
 Increased metabolic rate
 Difficulty consuming calories
 Low iron and glycogen stores
 Equipment

46. Nutrition for the Preterm
 IV total parenteral nutrition and lipids
 Gavage feedings
 Calorie requirement
 Fluid requirement
 High insensible water loss
 Urine output
 Signs of feeding intolerance