2. HIGH RISK NEWBORN
High risk newborn is defined as a
newborn, regardless of gestational age
or birth weight , who has a greater
than average chance of mortality or
morbidity because of conditions or
circumstances associated with birth
and the adjustment to existance
3. Classification according to size
Low birth weight infant
Very low weight infant
Extremely low birth weight infant
5. Low birth weight
Low birth weight is less than 2500gm
irrespective of the gestational age
6. Etiology
Causes is unknown
Uterine anomalies
Previous obstetric history
Multiple Pregnancy
Maternal disease in Pregnancy
Infection
Chronic diseases
Fetal causes
7. Classsification
Pre term
The growth potential is normal and is appropriate for
the gestational period
Small for gestational age
The term is to designate the newborns with birth
weight less than 10 percentile
A fetus of small for gestational may be constitutionally
small or due to pathologic process there may be fetal
growthrestriction
8. Birth weight is the single most important marker o
f
adverse perinatal and neonatal outcome.
Babies with a birth weight of less than 2,500g,
irrespective of their gestation are classified as low
birth weight babies.
These include both preterm and small-for-dates
babies.
9. Preterm infants (also called premature infants) are
those born before the beginning of 38th week of
gestation.
Moderately preterm infants are those born between 32
and 36 completed weeks of gestation.
Late preterm infants fall in the moderately preterm
group.
Very preterm infants are those born before 32
completed weeks of gestation. (Mehrban Singh,2010)
10. About 10 to 12 percent of Indian babies are born
preterm ( less than 37 completed weeks) as
compared to 5 to 7 percent incidence in the west.
These infants are anatomically and functionally
immature and therefore their neonatal mortality is
high.
11. The mechanisms initiating normal labour are not
clearly understood and much less is known about
the triggers that initiate labour before term.
Spontaneous
Induced
12. Poor socio-economic status
Low maternal weight
Chronic and acute systemic maternal
illness
Antepartumhemorrhage
Cervicalincompetence
Maternal genital colonization and
infections
14. The labour is often induced before term when there is
impending danger to mother or foetal life in-utero.
Maternal diabetes mellitus
Placental dysfunction as indicated by unsatisfactory
foetal growth
Eclampsia
Foetal hypoxia
Antepartum haemorrhage and
Severe rhesus iso-immunization.
15.
16. Their size is smallwith
relatively large head.
Crown-heel length i
s
less than 47cm
Head circumference is
less than 33cm but
exceeds the chest
circumference by more
than 3cm.
17. The general activityi
s
poor
Their automatic reflex
responses such as moro
response, sucking and
swallowing are sluggishor
incomplete.
The baby assumes an
extended posture dueto
poor tone.
18. Disproportionately
large head size
Sutures are widely
separated and the
fontanels are large
Small chin,
protruding eyes due
to shallow orbits and
absent buccal pad
of fat.
19. Optic nerve isoften un-
myelinated but presenceof
papillary membrane makes
its visualization difficult.
Ear cartilage isdeficiento
r
absent with poor recoil.
Hair appear woolly and
fuzzy and individual hair
fibres can be seen
separately.
20. skin is thin,gelatinous,
shiny and excessively
pink with abundant
lanugo andvery little
vernix caseosa.
Edema may be
present.
29. The closure ofductus
arteriosus isdelayed.
Ingrossly immature
infants( less than 32
weeks) EKG showsleft
ventricular
preponderance.
Risk to develop thrombo-
embolic complications
and hypertension.
30. Due to poor and
incoordinated suckingand
swallowing.
Animal fat is not tolerated a
s
well as the vegetablefat.
Regurgitation and aspiration
are common.
Hypoglycaemia
31. Abdominal distention and
functional intestinal
obstruction
Entero-colitis
Immaturity of theglucuronyl
transferase system in theliver
leads to hyper-bilirubinemia.
Development ofkernicterus
at lower serum bilirubin
levels.
32. Hypothermiais invariable.
Excessive heat loss due to
relatively large surfacearea
due to paucity of brown fat
in the baby who is
equipped with an
inefficient thermostat.
33. Infections are theimportant
cause of neonatal mortality.
The low levels of IgG
antibodies and inefficient
cellular immunity
Excessive handling, humid
and warm atmosphere,
contaminated incubators
and resuscitators expose
them to infectingorganisms.
34. The blood urea nitrogen is
high due to low glomerular
filtrate rate.
The renal tubular ammonia
mechanism is poorly
developed thus acidosis
occurs early.
They vulnerable to
develop late metabolic
acidosis especially when
fed with a high protein milk
formula.
Concentration of urine i
s
poor.
35. Preterm has to pass
4 to 5 ml of urine excrete
one milliosmole of solute
Baby gets dehydrated.
The solute retention and
low serum proteinsexplain
occurrence of edema in
preterm infants.
37. Develop anemia around 6
to 8 weeks of age.
Deficiencies of folic acid
and vitaminE.
Develop haemolytic
anemia, thrombocytopenia
and edema 6 to 10 weeks
of age.
Osteopenia and rickets
38. These babies are
prone to develop :
Hypoglycaemia
Hypocalcemia
Hypoprotenemia
Acidosis and
Hypoxia.
39.
40. Bed rest and sedation.
Tocolytic agents
Sympathomimetic agents-beta-2-adrenergic
receptors.
Isoxsuprine (duvadilan)-beta-1 and beta-2receptors.
Ritodrine
Salbutamol andterbutaline -beta-2 receptor
Magnesium sulphate
Indomethacin
41. Maturity of fetus should be ascertained by
examination of amniotic fluid for phosphatidyl
glycerol or L/Sratio.
Corticosteroids should be administered to t
h
e
mother to enhance fetal lung maturity.
42. Inj.betamethasone12mg IM
every 24 hours --2doses or
dexamethasone 6mg IM
every 12 hours for 4doses.
The optimal effect is seen if
delivery occurs after 24
hours of the initiation of
therapy and its therapeutic
effect lasts for 7days.
43.
44. Delayed clamping of cord.
Elective intubation of extremely LBW babies (<1000g).
Should be promptly dried, kept effectively covered and
warm.
Vitamin K 1mg ( 0.5mg in babies <1500g) should be
given intra-muscularly.
Transferred by the doctor or nurse to the NICU as soon a
s
breathing isestablished.
45. Vital signs.
Activity and behaviour.
Colour.
Tissueperfusion.
Fluids, electrolytes and ABG’s.
Tolerance of feeds .
Watched for developmento
f
RDS, apneic attacks, sepsis,
PDA, NEC, IVH,etc.
Weight gain velocity.
46. The vital signs should be stable.
The healthy baby is alert and active, looks
pink and healthy, trunk is warm to touch and
extremities are reasonably warm and pink.
The baby is able to tolerate enteral feeds and
there is no respiratory distress or apneic attacks
and baby is having a steady weight gain of 1-1.5 %
of his body weight every day.
47. Create a soft, comfortable,
“nestled” andcushioned bed.
Avoid excessive stimuli.
Effective analgesia and
sedation.
Provide warmth.
Ensure asepsis.
Prevent evaporative skinlosses.
48. Provide effective and safe
oxygenation.
Partial parenteral nutrition
and give trophic feeds
with expressed breastmilk
(EBM).
Provide rhythmic
gentle tactile and
kinaesthetic
stimulation.
49. Thermo-neutral
environment.
Application of oil or liquid
paraffin on theskin.
Should be covered with a
cellophane or thin
transparent or thin
transparent plastic sheet.
Provide partial
kangaroo0mother-care.
50. Oxygen should be administered
with a head box when SpO2 falls
below 85%and it should be
gradually withdrawn whenSpO2
goes above 90%.
The lowest ambient concentration
and flow rates should be used to
maintain SpO2 between 85-95%
and PaO2 between 60-80 mmHg.
51. Early phototherapyis
adviced to keep the serum
bilirubin level within safe
limits in order to obviate the
need for exchange blood
transfusion.
52. The handling should be b
a
r
e
minimum.
Vigilance should be
maintained on all
procedures.
Early diagnosis and prompt
treatment of infections.
53.
54. Intra-venous dextrose solution (
10% dextrose in babies >1000g
and 5%dextrose in babies
<1000g).
Trophic feeds with EBM through
NG tube.
Condition is stabilized -e
n
t
e
r
a
l
feeds.
55. Fluid requirements are higher in LBW infants due
to:
Greater insensible water losses
Faster breathing rates
Decreased ability to concentrate urine
Greater use of radiant warmers
Greater use of phototherapy units
57. Fluid rate can be increased by 10-20 ml/kg/dto
gradually reach 150 ml/kg/d
Fluid requirements need to be
individualized for each baby
Enteral nutrition has to be considered once
the baby is stable
58. Infants with BW ≤ 1000 g
Infants with BW ≤ 1500 g, done in
conjunction with slowly advancing enteral
nutrition
Infants with BW 1501-1800 g for whom
enteral intake is not expected for > 3 days
60. Trophic feeding/ Gut priming
Practice of feeding very small amounts of enteral nourishment
to stimulate development of the immature GIT
Advantages:
Improves GI motility
Enhances enzyme maturation
Improves mineral absorption
Lowers incidence of cholestasis
Shortens time to regain birth weight
61. Breast milk or ½ or full strength preterm formula at
10ml/kg/d by intermittent gavage/ continuous
nasogastric drip
Increase by 10-15 ml/kg/d to reach 150ml/kg/d
Increments not >20 ml/kg/d
IV fluids can be stopped once 120ml/kg/d is reached
On reaching 150ml/kg/d,calorie density can be
increased
62. PRETERMS
<1200 g/ <32 wks: IV fluids for first 2-3 days, once
stable start gavage feeding
1200-1800 g/ 32-34 wks: Start gavage feeding, o
n
c
e
vigorous start spoon/ breast feeding
>1800 g/ >34 wks: Start breast feeding directly; if
trial feed takes>20 mins or intake is less than
required, switch to gavage feeding
63. Advantages:
Higher concentrations of amino acids
Higher concentrations of essential fatty acids
Lower renal solute load
Specific bio-active factors provide immunity
Promotes intestinal maturation
67. Gentle touch, massage,
cuddling, stroking and flexing.
Rocking bed or placing a
preterm baby on inflated
gloves.
Soothing auditory stimuli.
Visualinputs.
68. Kangaroo care is placing a
premature baby in an upright position on a
mother’s bare chest allowing tummy to
tummy contact and placing the premature
baby in between the mother’s breasts.
The baby’s head is turned so that the ear i
s
above the parent’sheart.
69. Bodyt
e
m
p
e
r
a
t
u
r
e
Mothers have thermal synchrony with their baby.
The study also concluded that when the baby was
cold, the mother’s body temperature would increase
to warm the baby up and vice versa.
71. Increase weightgain
Kangaroo care allows the baby to fall into a deep
sleep which allows the baby to conserve energy for
more important things. Increased weight gain
means shorter hospital stay.
75. Loss is upto a maximum of 1
0
to 15percent.
Regain their birth weight b
y
the end of second week of
life.
Excessive weight loss, delay in
regaining the birth weight or
slow weight gain- suggest
baby isnot being fed
adequately or unwell and
needs immediate attention.
77. Itisdesirable to administer0
-
day vaccines(BCG, OPV,
HBV) on the day of
discharge from thehospital.
Ifmother isHBV carrier and i
s
e-antigen positive- hepatitis
Bvaccine and hepatitis B
specific immunoglobulins
within 72 hours of age.
78. Live vaccines should be
avoided in symptomatic HIV-
positive mothers.
WHO recommends that BCG
and oral polio vaccine can be
given to asymptomatic HIV-
positive infants.
79. The family dynamics a
r
e
greatly disturbed.
The problems and issues
should be handled with
equanimity, compassion,
concern and caring attitude
of the healthteam.
Encouraged to touch and
talk with herbaby.
Providekangaroo-mother-
care.
Emotional support and
guidance.
80. A baby who is feeding from the
bottle or cup and is reasonably
active with a stable body
temperature, irrespective of his
weight, qualifies for transfer to the
open cot.
81. The mother should be
mentally prepared and
provided with essential
training and skills.
The mother- baby dy
ad
should be kept in step-
down nursery.
The baby should be
stable, maintaining his
body temperature and
should not have any
evidences of cold stress.
82. At the time of discharge,
the baby should be having
daily steady weight gain
velocity of at least 10g/kg.
The homeconditions
should be satisfactory
before the baby is
discharged.
The public health nurse
should assess the home
conditions and visit the
family at home every week
for a month or so.
84. Neuro-motor development,
cognition and seizures.
Eyes: Retinopathy of
prematurity, vision,strabismus.
Hearing.
Behavioural problems,
language disordersand
learning disabilities.
85. She must be explained
aboutthe importance of
asepsis.
Keeping the baby warm
and ensuring satisfactory
feeding routine.
The services of
postpartum programme
public health nurse and
social worker can be
utilized.
86. The infant should be effectively covered taking care to
avoid smothering.
Woollen cap, socks and mittens should be worn.
The infant should preferably lie next to the mother.
Inwinter, the room can be warmed with a
radiant heater or angeethi.
A table lamp having 100 watt bulb can be used to
provide direct radiantheat.
Hot water bottle should never come in contact with
the baby.
87. The cot of the mother and infant should be located
away from thewalls .
The mother and health worker should be trained to
assess the temperature of the newborn baby by touch.
The visitors and handling of the infant should be
restricted to the bare minimum.
The hands must be washed before touching or
feeding the baby.
The emotional urge for kissing the baby should be
curbed.
The linen should be clean and sun-dried.
88. Whenever feasible, breast feeding is ideal and
must be encouraged.
When infant is unable to suck from the breast, E
B
M
should be given with a bottle or dropper or spoon
or paladay depending upon his maturity.
Formula for premature babies is recommended.
If cow’s or buffalo’s milk is unavoidable it should be
given after 3:1dilution.
Mother must be given detailed instructions and
practical demonstration for maintenance of bottle
hygiene to prevent contamination of feeds.
89. The riskof neurodevelopmental
handicaps isincreased3-fold for LBW
babies and 10-fold for very LBW
babies(<1500g).
The prognosis isgood if nobirth
asphyxia, apneic attacks,RDS,
hypoglycaemia and
hyperbilirubinemia.
Preterm AFD babies catch up in
their physical growth with term
counterparts by the age of 1 to 2
years.
90. 15 to 20 %
incidence of
neurological handicaps in the
form of CP, seizures, ROP,
hydrocephalus, deafness and
MR.
There ishigh incidence of
minor neurologic disabilities.
Neurological prognosis is
adversely affected bydegree
of immaturity.
91. Obtain detailed antenatal, intra-
natal history.
Assess the gestational age and
birth weight of the baby.
Assess the features ofclinical
immaturity.
Assess the behaviour of preterm
neonate.
Assessment of c
o
m
m
o
n
problems.
92.
93. 1. Impaired gas exchange related to immaturity of
lungs and deficiency of surfactant
Assess the respiratory pattern and colour of t
h
e
baby
Observe for any apneic episode.
Oxygen hood is often used for able to
breathe alone but need extra oxygen.
Oxygen also may be given by nasal cannula to t
h
e
infant who breathesalone.
Humidify the oxygen
CPAP may be necessary to keep the alveoli open
and improve expansion of lungs
94. 2.Impaired breathing pattern :distress related to
immaturity and surfactantdeficiency
Assess the respiratory rate, heart rate and c
h
e
s
t
retractions
Position the child for maximal ventilatory efficiency
and airway patency
Provide humidified oxygen
Spo2monitoring
Providesuctioning
Provide chest physiotherapy
Administerbronchodilators
Administer anti inflammatory medications
Administerantibiotics
95. 3. Activity intolerance related to increased work of
breathing secondary todistress
Arrange to provide routine care
Schedule periods of uninterrupted rest
Determine infant’s stress level
Reduce nonessential lighting
Use positioningdevices
96. 4. Ineffective airway clearance related to excessive
trachea-bronchial secretions
Assess the child’s breathing pattern
Checkthe vital signs
Provide suctioning
Provide humidifiedoxygen
Assess the ABG analysis
Provide C-PAP using mask /hood/nasal prongs
Observe for risksof C-PAP
Assist in CMV with PEEP if needed
97. 5. Hypothermia related toimmature thermoregulation
system
Monitor vitalsigns frequently
Wrap the baby well and keep warm
Provide small and frequent breast feeding as tolerated
Look forhypoglycemia
Administer IV fluids if not tolerating the feed
Monitor the vital signs and blood pressure
Assess the skin tone, pallor and signs of dehydration
Administer IVfluids
98. 6. Imbalanced nutrition less than bodyrequirement
related to feeding difficulty, respiratory distress, or
NPO status
Assess the sucking and swallowing ability of t
h
e
newborn
Assess the tolerance of the child
Monitor the blood glucose level frequently
Administer IV fluids if not tolerating oral fluids
Administer human milk fortifier if the child is preterm
99. 7. Fatigue related to increased demand for nutrients
and deterioration of the general condition of the
baby
Assess the general condition of the baby
Assess the level of activity
Monitor the blood glucose level
Breast fed the baby
Check for from any part of the body
Provide top up feed
100. 8. Risk for complications hypotension, shock, cerebral
hypoxia related to progression of the disease condition
Assess the vital signs, respiratory rate, pulse rate,
temperature and bloodpressure
Check blood culture and sensitivity and sepsis screening
Monitor for any signs of dehydration
Administer IV fluids or blood as necessary
Assess the serum electrolyte values and ABG values
Closely monitor for the early signs and symptoms o
f
complications
101. 9. Anxiety of parents related to the outcome of the
newborn condition
Assess the mental status, anxiety and knowledge of
family members
Assess the supporting system for the family
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the care giver
Provide psychological support to the family
members
102. 10. Interrupted mother-child bonding relatedto
infectious process
Assess the breast feeding ability including
sucking and swallowing ability
Keep the child with the mother if possible
Provide frequent breast feed 2 hourly
If breast feeding is not tolerated give EBM
Allow the mother to visit the child
Provide kangaroo mother care in case of pre term if
tolerated
103. 11. Interrupted family process relatedto
hospitalization of thenewborn
Assess the mental status, anxiety and knowledge
of familymembers
Encourage mother-child bonding if possible
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the
care giver
Allow the family members to visit the child
104. 12. Knowledge deficit regarding care of the baby
and treatmentmodalities
Assess the knowledge level of the care giver
Explain disease condition and it’s progress to t
h
e
family members
Educate regarding treatment and its prevention
Educate about the monitoring of the baby
Provide adequate explanation regarding
nutritional need of thebaby
Clarify their doubts and promote understanding
105. Definition and incidence
Causes of prematurity
Clinical features
Physiological handicaps
Management
Careof preterm babies
Prognosis
Nursing assessment
Nursing diagnosis and
interventions
