CONCEPT, ASSESSMENT, GOALS, OBJECTIVES OF

HIGH RISK NEWBORN

INTRODUCTION
A newborn should have a thorough evaluation performed within 24 hours of birth to
identify any abnormality that would alter the normal newborn course or identify a medical
condition that should be addressed (e.g., anomalies, birth injuries, jaundice, or
cardiopulmonary disorders) . This assessment includes review of the maternal, family, and
prenatal history and a complete examination. Depending upon the length of stay, another
examination should be performed within 24 hours before discharge from the hospital.

The high-risk period begins at the time of viability (the gestational age at which
survival outside the uterus is believed to be possible, or as early as 23 weeks of gestation)
up to 28 days after birth and includes threats to Life and health that occur during The
prenatal, perinatal, and postnatal periods.

CONCEPT OF HIGH RISK NEWBORN

MEANING OF NEONATE
From birth to under four weeks of age (<28 days), the infant is called neonate or
newborn. First week of life (<7 days or <168 hours is known as early neonatal period. Late
neonatal period extends from 7th to < 28th day.
DEFINITION OF HIGH RISK NEWBORN
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
extrauterine existence.
Encompasses human growth and development from the time of viability 28 days
following birth and includes threat to life and health that occur during the prenatal,
perinatal, and postnatal periods.

CLASIFICATION OG HIGH RISK NEWBORN

High-risk infants are most often classified according to birth weight, gestational age,
and predominant pathophysiologic problems. The more common problems related to
physiologic status are closely associated with the infants state of maturity and usually
involve chemical disturbances (e.g., hypoglycemia, hypocalcemia) and consequences of
immature organs and systems (e.g., hyperbilirubinemia, respiratory distress, hypothermia).

CLASSIFICATION ACCORDING TO SIZE

 Low-Birth-Weight (LBW) InfantAn infant whose birth weight is less than 2500 g
(5.5 lb), regardless of gestational age
Very LowBirth-Weight (VLBW) InfantAn infant whose birth weight is less than
1500 g (3.3lb)
Extremely LowBirth-Weight (ELBW) InfantAn infant whose birth weight is less
than 1000 g (2.2 lb)
Appropriate-For-Gestational-Age (AGA) InfantAn infant whose weight falls
between the 10th and 90th percentiles on intrauterine growth curves.
Small-For-Date (SFD) Or Small-For-Gestational-Age (SGA) InfantAn infant
whose rate of intrauterine growth was slowed and whose birth weight falls below
the 10th percentile on intrauterine growth curves.
Intrauterine Growth Restriction (IUGR)Found in infants whose intrauterine
growth is retarded (sometimes used as a more descriptive term for the SGA infant)
Large-For-Gestational-Age (LGA) InfantAn infant whose birth weight falls above
the 90th percentile on intrauterine growth charts

CLASSIFICATION ACCORDING TO GESTATIONAL AGE

Preterm (premature) infantAn infant born before completion of 37 weeks of
gestation, regardless of birth weight
Full-Term InfantAn infant born between the beginning of 38 weeks and the
completion of 42 weeks of gestation, regardless of birth weight
Posterm (Postmature) InfantAn infant born after 42 weeks of gestational age,
regardless of birth weight
Late-Preterm InfantAn infant born between 34 and 36 weeks of gestation,
regardless of birth weight

CLASSIFICATION ACCORDING TO MORTALITY

Live BirthBirth in which the neonate manifests any heartbeat, breathes, or
displays voluntary movement, regardless of gestational age
Fetal DeathDeath of the fetus after 20 weeks of gestation and before delivery,
with absence of any signs of life after birth
Neonatal DeathDeath that occurs in the first 27 days of life; early neonatal death
occurs in the first week of life; late neonatal death occurs at 7 to 27 days
Perinatal MortalityDescribes the total number of fetal and early neonatal deaths
per 1000 live births
Postnatal DeathDeath that occurs at 28 days to 1 year after birth

CLASSIFICATION ACCORDING TO BIRTH WEIGHT

Low Birth Weight - Birth weight less than 2500g regardless of gestational age
Moderately Low Birth Weight - birth weight is between 1501g to 2500g.
Very Low Birth Weight -birth weight is less than 1500g.
Extremely Low Birth Weight - birth weight less than 1000g.

CLASSIFICATION ACCORDING TO SIZE

Appropriate for Gestational Age (AGA) - birth weight falls between the 10 and 90
percentile
 Small for Gestational Age ( SGA) - birth weight falls below the 10 percentile
Large for Gestational Age (LGA)- birth weight falls above the 90 percentile

MEDICALLY HIGH RISK NEWBORN (MHRN) ELIGIBILITY CRITERIA

PREMATURITY (less than 32 weeks gestation)

VERY LOW BIRTH WEIGHT (less than 1500 grams)
SIGNIFICANTLY SGA (small for gestational age) failure to thrive, IUGR (intrauterine
growth retardation) less than 5th percentile.
PROLONGED hypoxemia, academia, repetitive apnea, required assisted ventilation
.40 hours.
METABOLIC PROBLEMS, i.e hypoglycemia, hypocalcemia
HYPERBILIRUBINEMIA (considered when persistent and untreated
hyperbilirubinemia requires exchange transfusions and/or is associated with
congenital anomalies).
NEONATAL SEIZURES or seizures beyond the neonatal period.
SERIOUS BIOMEDICAL FACTORS i.e. CNS bleeds, RDS (respiratory distress
syndrome) confirmed infection, chronic lung disease.
MULTIPLE CONGENITAL ANOMALIES requiring special services, but with presumed
potential for normal developmental outcome.
HISTORY OF MATERNAL CHEMICAL EXPOSURE and/or substance abuse i.e. alcohol
hydantoin, warfarin and cocaine.
PERSISTENT FEEDING PROBLEMS
PERSISTENT TONAL PROBLEMS
CONTINUED evidence of delay in one or more developmental areas and poor
parent-infant attachment.

IDENTIFICATION OF HIGH RISK NEWBORNS

Maternal diabetes
Maternal narcotics during labor
Maternal substance abuse
Fetal asphyxia
Difficult/prolonged labor causing birth trauma
Multiple gestation
Preterm or postterm delivery
Congenital anomalies
Maternal or neonatal infection
SGA or LGA
Apgar score < 6 at 1 min or < 7 at 5 min
 PRETERM INFANTS
MEANING - An infant born before term (<=36 weeks); A low birth weight infant: </=1300-
2000g (Philippine Standards) (,2.5kg)
A newborn born before complete maturity; born before body and organ system
have completely matured is called prematurity.

INCIDENCE:
Highest among low socio economic class
Largest - of admission to NICU
12% of all pregnancies
CAUSES
Unknown
Maternal Factor
Malnutrition
Preeclampsia (toxemia of pregnancy)
Chronic Medial illness (Cardiac/kidney disease/DM)
Infection (UTI, vaginal infection)
Drug Use (coccaine, tobacco, alcohol)
Abnormal structure of the uterus
Previous Preterm Births
Pregnancy Related Causes
Hypertension
Incompetent Cervix
Placental Previa/ Abruptio Placenta
PPROM, poly/oligohydramnios
Fetus
Chromosomal abnormalities
Intrauterine Infection
Anatomic Abnormalities
IUGR
Multiple gestations
DIAGNOSTIC EVALUATION
Appraisal is made as soon as possible after admission to the nursery.
HEAD
Head circumference is large in comparison with chest (reflects cephalocaudal
direction of growth)
The fontanels are small and bones are soft - Soft cranium subject to characteristic
non-intentional deformation.
Bones of skull and ribs - soft Very small and appear scrawny,
EYES
Absent eyebrows
Eyes closed
EARS
Ears are poorly supported by cartilage (soft and pliable)

SKIN
Bright pink (often translucent) with small blood vessels
Smooth and shiny (may be edematous) with small blood vessels clearly visible
underneath thin epidermis
Fine lanugo hair abundant over body, sparse, fine & fuzzy on head
Less subcutaneous fat (skin is wrinkled)
SOLES AND PALMS
Minimal creases
HARLEQUIN COLOR
Skin color changes when preterm infant is moved;
Upper half or one side of the body is pale or one side of the body is red.
CHEST
Small breast bud size with underdeveloped nipples
GENITALIA
Male Infants - few scrotal rugae, undescended testes
Female infants- Labia and clitoris are prominent in females
POSTURE
Complete relaxation with marked flexion and abduction complete relaxation with
marked flexion and abduction of the thighs;
Random movements are common with slightest stimulus
ACTIVITY
Inactive and listless

EXTREMITIES
Extremities maintain an attitude of extension and remain in any position in which
they are placed.
REFLEXES
partially developed
Sucking absent, weak or ineffectual; swallow, gag, cough reflexes - ABSENT
TEMPERATURE INSTABILITY
Heat regulation poorly developed in the preterm infant because of poor
development of CNS
IMMUNITY
Increased susceptibility to infection
RESPIRATION
Respirations are not efficient because of muscular weakness of lungs and rib cage
and limited surfactant production;
Retraction at xiphoid is evidence of air hunger
Infants should be stimulated if apnea occurs
HMD/RDS, chronic lung disease, BPD, apnea of prematurity
CIRCULATION
Greater tendency toward capillary fragility in the preterm infant
 Red and white blood cell counts are low with resulting anemia during first few
months of life.
NEUROMUSCULAR
Neuro - Higher incidence of intracranial hemorrhage in the preterm infant
Muscle twitching, convulsions, cyanosis, abnormal respirations, and a short shrill
cry
Cerebral palsy, visual -motor deficits, altered intellectual functions
GASTROINTESTINAL TRACT
Nutrition is difficult to maintain because of weak sucking and swallowing reflexes,
small capacity of stomach, and slow emptying time of the stomach
RENAL
Reduced glomerular filtration rate results in decreased ability to concentrate urine
and conserve fluid.
Higher ECF, vulnerable to fluid and electrolyte imbalance
PREVENTION
Prenatal Care
Good nutrition and education
Identification of mothers at risk
Educate on symptoms of PT labor
Avoid heavy/repetitive work or standing long periods of time
TREATMENT
Oxygen, IVF
Umbilical catheterization
Intravenous Fluid
Medications
Blood Intravenous Fluid extraction
X-ray
Special feedings of breast milk/formula
Kangaroo care
NURSING CARE
Maintain airway
Check respirator function if employed
Position to promote ventilation
Suction when necessary
Maintain temperature of environment
Administer oxygen only if necessary
Observe for changes in respirations, color, and vital signs
Check efficacy of Isolette
Maintain heat, humidity, and oxygen concentration; monitor oxygen carefully to
prevent retrolental fibroplasias
Maintain aseptic technique to prevent infection
Monitor for hypoglycemia ,hyperbilirubinemia & hemorrhage
Careful skin care & positioning to prevent breakdown
Adhere to the techniques of gavages feeding for safety of the infant
Observe weight -gain patterns
Determine blood gases frequently to prevent acidosis
 Institute phototherapies by letting them verbalize and ask questions to relieve
anxiety
Provide flexible and liberal visiting hours for parents as soon as possible
Allow parents to do as much as possible for the infant after appropriate teaching
Arrange follow-up before and after discharge .

POSTMATURE INFANTS
MEANING
Baby born after 42 weeks AOG/ 294 days past 1st day of mothers LMP; regardless of
birth weight is referred to as postmature infants.
OTHER NAMES- Post term, post maturity, prolonged pregnancy, post datism

INCIDENCE
7% (3.5 -15%) of all pregn ancies
CAUSES
Unknown
History of >/= 1 previous post term pregnancies
Miscalculated due date (not sure of LMP)
Fetal Risk
Progressive placental dysfunction placenta (supplies nutrient & oxygen) ages
toward the end of pregnancy ---may not function efficiently
Amniotic fluid volume decreases, fetus may stop gaining weight/ weight loss
Decreased amniotic fluid may lead to cord compression during labor
Increased risk of MAS and hypoglycemia
Increasing size (mainly length) & hardening of skull may contribute to CPD
GRE ATEST RISK: during stresses of labor & delivery especially in infants of
primigravidas.
CHARACTERISTICS OF INFANTS
Absent lanugo,
Little if any vernix caseosa,
Abundant scalp hair,
Overgrown nails
Dry, peeling skin (cracked, parchmentlike & desquamating)
Wasted physical appearance (reflects intrauterine deprivation)
Minimal fat deposit (depleted subcutaneous fat) thin, elongated appearance
Meconium staining - seen in skin folds w/ vernix caseosa
Visible creases palms/ soles
DIAGNOSIS:
Physical Examination
Ultrasound Scanning
Non -stress testing
Estimate amniotic fluid volume
MANAGEMENT
Check respiratory problems related to meconium
Suctioning
Blood test for hypoglycemia
PREVENTION
Accurate due date and Ultrasound Scanning
Cesarean section/ induction of labor -recommended.
HIGH RISK RELATED TO PHYSIOLOGIC FACTORS
HYPERBILIRUBINEMIA
MEANING- Hyperbilirubinemia refers to excessive level of accumulated Bilirubin in the
blood
JAUNDICE or ICTERUS- yellowish discoloration of skin, sclera, nails. Relatively benign but
it can also be pathologic

PATHOPHYSIOLOGY
RBC Destruction

Globin Heme

Protein (used by the body) Unconjugated Bilirubin

Liver

Bilirubin detached from albumin through enzyme glucoronyl transferase or glucoronic acid

Conjugated Bilirubin

Excreted into Bile (feces and urine)

Hyperbilirubinemia - Result from increased unconjugated/ conjugated bilirubin

Bilirubin - one of the breakdown products of one of the breakdown products of hgb from
RBC destruction
Unconjugated Bilirubin - insoluble, bound to insoluble, bound to albumin
Intestines (or) bacterial action - reduces conjugated bilirubin
Urobilinogen - pigment that gives stool its characteristic odor.
COMPARISION OF MAJOR TYPES OF UNCONJUGATED HYPERBILIRUBINEMIA
PHYSIOLOGIC BREAST-FEEDING BREAST MILK HEMOLYTIC
JAUNDICE ASSOCIATED JAUNDICE (LATE DISEASE
JAUNDICE (EARLY ONSET)
ONSET)

CAUSE

Immature hepatic Decreased milk Possible factors is Blood antigen

functionor increased intake related to breast milk that incompatibility
bilirubin load from fewer calories prevent bilirubin causes hemolysis of
RBC hemolysis consumed by infant conjugation less large # of RBCs.
before mothers milk frequent stooling Liver unable to
is well established conjugate and
enterohepatic excrete excess
shunting bilirubin form
hemolysis.

ONSET

After 24 hours 2nd- 4th day 5th 7th day During 1st 24 hrs
(preterm infants, (levels increase
prolonged) faster than
5mg/day)

PEAK

75- 90 hours 3rd 5th day 10th 15th day Variable

DURATION

Declines on 5th 7th Variable May remain Dependent on

day jaundiced x 3-12 severity and
weeks or more treatment

THERAPY

Increase frequency Frequent (10 Increase frequency Monitor TcB/TSB

of feedings and avoid 12x/day) breast of breast feeding; level. Perform risk
supplements. feeding, avoid use no assessment
Evaluate stooling glucose water, water supplementations POSTNATAL-
pattern. Monitor supplements or (glucose water): phototherapy;
transcutaneous formula. Evaluate cessation of administer IVIG per
bilirubin (TcB)/ stooling pattern; breastfeeding not protocol; if severe,
Total Serum stimulate as needed. recommended. perform exchange
Bilirubin (TSB) Perform risk transfusion.
assessment.

THERAPY :

Perform risk Use phototherapy if Consider performing PRENATAL

assessment. Use bilirubin level additional transfusion (fetus)
phototherapy if increases evaluations: G6PD, prevent sensitization
bilirubin level significantly (17-22 direct and indirect (Rh incompatibility)
increases mg/dl) or significant serum bilirubin, of Rh- negative
significantly hemolysis is present. family history and mother with Rhig
(>5mg/dl/day) or others as necessary. (Rhogam)
significant hemolysis
is present

BREAST FEEDING. BREAST MILK JAUNDICE HEMOLYTIC DISEASE

ASSOCIATED JAUNDICE (LATE ONSET)
(EARLY ONSET)

THERAPY:

If phototherapy is instituted, May include home PRENATAL if mother Is

evaluate benefits and harm phototherapy with a breastfeeding, assist with
of temporarily discontinuing temporary (10-12hr) maintenance and storage of
breastfeeding; additional discontinuation of a milk; may bottle-feed
assessments may be breastfeeding, a subsequent expressed milk as
required. Assist mother with TSB may be drawn to appropriate to therapy.
maintaining milk supply, evaluate a drop in serum Minimize maternal- infant
feed expressed milk as levels. separation and encourage
appropriate. After discharge, contact as appropriate.
Assist mother with
follow up according to hour
maintenance of milk supply
of discharge.
and reassurance regarding
her milk supply and therapy.

Use formula supplements

 only at practitioners
discretion.

CAUSES
Physiologic (developmental) factors (prematurity):
Excess production of bilirubin - Hemolytic disease, biochemical defects, bruises
Hemolytic disease - blood antigen incompatibility blood antigen incompatibility,
hemolysis of RBC; liver unable to conjugate & excrete excess bilirubin from
hemolysis
PHASES OF PHYSIOLOGIC JAUNDICE
2 PHASES: TERM INFANTS
1ST phase - Bilirubin: 6mg/dl on 3rd day
Date Of Labour : decreased to 2--3mg/dl by 5th day
2 phase - Steady plateau without increase/decrease level
nd

12th -14th day: levels decreased to normal (1mg/dl)

Pattern varies according to racial group, method of feeding, gestational age
PRETERM: Bilirubin - 10-12mg/dl at 4-5days slowly decrease by 2-4 weeks.
CLINICAL MANIFESTATIONS
Jaundice most obvious sign
Yellowish discoloration: sclera, nails, skin
If it appears within 1st 24 hours: hemolytic disease of Newborn, sepsis, maternally-
derived diseases (DM, infections)
Appears on 2nd or 3rd day, peaks on 3rd 4th day, declines on 5th 7th day: physiologic
jaundice (varies according to ethnicity)
Intensity of jaundice is not always related to the degree of hyperbilirubinemia

BREASTFEEDING JAUNDICE (Early onset)

Early onset Begins at 2--4days of age; 12-13% of Breastfeeding infants
Related to process of breastfeeding, results from decreased caloric & fluid intake by
Breastfeeding infants before milk supply is well-established (fasting is associated
with decrease established (fasting is associated with decreasehepatic clearance of
bilirubin)
Feeding (or) peristalsis more rapid passage of meconium more rapid passage of
meconium decreased amount of reabsorption of unconjugated bilirubin
Feeding introduces bacteria to aid in reduction of bilirubin to urobilinogen
Colostrums, natural cathartic, facilitates meconium evacuation
BREAST MILK JAUNDICE (late onset)
Late onset : 4th -7th day of age; 12-13% of Breastfeeding infants
Rising levels peak at 2nd week gradually diminish. May remain jaundiced x 3-12
weeks or more 12 weeks or more infants are well
May be caused by factors in Breast Milk (pregnanediol, fatty acids, B- glucorinidase)
that either inhibit conjugation or decrease excretion of bilirubin
Less frequent stooling by Breastfeeding infants may allow for extended time for
reabsorption of bilirubin from stools
 Excess production of bilirubin - Hemolytic disease, biochemical defects, bruises
DIAGNOSITC EVALUATION
Serum Bilirubin (B1: 0.2-1.4mg/dl)
Jaundice appears at >5mg/dl
Evaluation based on:
Timing of appearance of clinical jaundice
Gestational age at birth
Age in days since birth
Family history including maternal Rh factor
Evidence of hemolysis
Infants physiologic status
Progression of serum bilirubin levels
Persistent jaundice over 2 weeks in full-term, formula fed term, formula fed infant
Total serum bilirubin levels 12.9mg/dl (term infant) or over 15mg/dl (preterm);
upper limit for breastfeeding infant 15mg/dl
Increase serum bilirubin >5mg/dl/day
Direct bilirubin (B2) 1.5 -2mg/dl
Total serum Bilirubin over 95th percentile for age (in hours)on hour--specific risk
nomogram
Transcutaneous Bilirubinometry , noninvasive monitoring of bilirubin via cutaneous
reflectance mechanisms; allow for repetitive estimations of bilirubin
Hour specific Serum Bilirubin Levels predict newborn at risk for rapidly rising
levels
Recommended by AAP for monitoring healthy Newborn >35wks AOG before
discharge from hospital
Carbon monoxide indices in exhaled breath CO is produced when RBC is broken
down
TREATMENT:
Postnatal
Phototherapy - main form
Exchange transfusion - reduce high bilirubin levels that occur with hemolytic
disease
Prenatal
Transfusion (fetus)
Phenobarbital hemolytic disease; effective when given to mother several days
before delivery
COMPLICATIONS
Bilirubin Encephalopathy/ Kernicterus- unconjugated bilirubin highly toxic to the
neurons
o Syndrome of severe brain damage due to deposition of unconjugated
bilirubin in brain cells (extremely high B1 level increase crosses the blood -
brain barrier)
Kernicterus- yellow staining of brain cells that may result in bilirubin
encephalopathy brain injury
Metabolic acidosis
 Low serum albumin level
Intracranial infections (meningitis)
Abrupt increase in BP
Conditions that increase metabolic demands for oxygen and glucose - fetal distress,
hypoxia, hypothermia, hypoglycemia

PROBLEMS RELATED TO BIRTH TRAUMA

FACIAL PARALYSIS
From pressure on facial nerve during delivery
Affected side unresponsive when crying
Resolves in hours/days

ERBS PALSY (ERB- DUCHENNE PARALYSIS)

Associated with stretching or pulling head away from shoulder during delivery
Signs: Flaccid arm, elbow extended, hand rotated inward, Moro & grasp reflexes
absent on affected side
Requires immobilization & reposition for 2 to 3 hrs

FRACTURED CLAVICLE
Bone most frequently fractured during delivery
Associated with CPD
Signs: limited ROM (range of motion), crepitus, absent Moro reflex on affected side
Heals quickly, handle gently, immobilize arm

ASPHYXIA
Inadequate tissue perfusion
Signs: acidotic scalp or cord pH
Low Apgar score (< 4 at 1 min)
Begin resuscitation immediately

NEONATAL RESPIRATORY DISTRESS

Common causes
o Preterm infants (Primarily associated with infants < 37 wks)
o Meconium aspiration syndrome (MAS):
o Transient tachypnea of the newborn (TTN): delayed fluid absorption in
lungs.
Signs
o Tachypnea
o Intercostal retractions
o Nasal flaring
o Expiratory grunting, diminished breath sounds
o PaO2 <50, PCO2 >60
o Central cyanosis (late finding)
 Interventions
o Radiant warmer or isolette to maintain neutral thermal environment &
prevent cold stress; oxygen demands increase if neonate is cold.
o Warmed, humidified oxygen
o Withhold feedings if RR > 60 breaths/min
o Position side lying or supine with neck slightly extended
o Suction the baby to maintain a patent airway
o Monitor oxygen saturation and/or ABGs as ordered

MECONIUM ASPIRATION SYNDROME (MAS)

Prenatal asphyxia causes relaxation of anal sphincter & passage of meconium into amniotic
fluid

Fetus/infant inhales meconium into airway

Forms mechanical obstruction; air can be inhaled but cant be exhaled

Lungs become hyper inflated

Irritating to airway

Causing chemical pneumonitis

Signs:
o Fetal distress
o Apgar score < 6 at 1 & 5 min,
o Distended
o Barrel-shaped chest,
o Diminished breath sounds,
o Yellow staining of skin, nails & cord

Interventions
o Suction oropharynx & nasopharynx after head is born & shoulders and chest
still in birth canal
o Endotracheal suctioning indicated before stimulating respirations unless
infant crying & vigorous
o Administer O2 and anticipate need for ventilation
o Perform chest physiotherapy routinely
TRANSIENT TACHYPNEA OF THE NEWBORN (TTN)
Failure to clear airway of excess fluid at delivery
Primarily term infants, especially if C/S (miss mechanical squeeze of vaginal
delivery)
Signs:
o Grunting
o Flaring
o Mild cyanosis
o Tachypnea, - respirations can be as high as 100 to 140 breaths/min
Nursing Management
o O2 as needed to maintain PO2
o Usually resolves within 72 hours

COLD STRESS
All newborns at risk for hypothermia
Keep temp 97.6-99.2 by
Neutral thermal environment
o Delay bath until temperature stable
o Dry iimmediately after bath
o Under warmer or skin to skin after delivery
o Wrap with warm blankets
o Check O2 sat and blood glucose
o Chronic hypothermia can be early sign of sepsis

HYPOGLYCEMIA
Blood glucose < 40 mg/dl in term newborn
At risk
o IDM (Infant of a Diabetes Mellitus)
o SGA (Small for Gestational Age)
o Premature
o Infants with cold stress
o Hypothermia
o Delayed feedings
Signs:
o Tremors
o Jitteriness
o Lethargy
o Decreased muscle tone
o Apnea
o Anorexia
Nursing Management
o Check blood glucose of at-risk infants,(30 min if IDM) & on any symptomatic
newborn.
o Feed (breast or bottle)
o Reassess glucose before next feeding
INFANT OF A DIABETIC MOTHER (IDM)

Maternal glucose crosses placenta

Fetal pancreas secretes more insulin to metabolize glucose

Increased insulin decreases surfactant production.

Signs
o LGA (Large for Gestational Age)
o Hypoglycemia
o RDS (Respiratory Distress Syndrome)
o False positive L/S ratio,
o Increased risk for congenital anomalies (especially cardiac and spinal)

Nursing Management
o Assess for birth trauma
o Monitor Blood glucose at 30 min and 1, 2, 4, 6, 9 12 and 24 hours
o Treat hypoglycemia

NEWBORN SEPSIS
Group B streptococcus most common cause
Complicated by immature immune system & lack of IgM
Associated with PROM
Prolonged labor
Maternal infection.

Signs:
o Lethargy
o Seizure activity
o Pallor
o Hypothermia
o Poor feeding
o Respiratory distress
o Apnea
o Tachycardia
o Bradycardia
o Hyperbilirubinemia

Nursing Management:
o Obtain cultures (blood, urine, CSF)
o Start antibiotics star. After 72 hrs,
o Treatment stopped if culture negative & asymptomatic.
o Continue antibiotics for 1014days if culture reports positive
FETAL ALCOHOL SYNDROME (FAS)
Alcohol crosses placenta

Interferes with protein synthesis

Increasing risk of congenital anomalies,

Mental deficiency & IUGR

Signs
o SGA
o Small eyes
o Flat midface
o Long, thin upper lip
o Flat upper lip groove
o Irritable
o Hyperactive
o High pitched cry

Nursing Management
o Reduce environmental stimuli
o Swaddle to increase feelings of security
o Sedatives for withdrawal side effects

NEONATAL ABSTINENCE SYNDROME (NAS)

Etiology
o Repeated intrauterine drugs exposure causes fetal drug dependency, degree
of withdrawal depends on type & duration of addiction

Signs
o Hyperactivity, jitteriness & shrill, persistent cry
o Frequent yawning & sneezing, nasal stuffiness
o Sweating
o Absence of step & head-righting reflex
o Developmental delays
o Feeding difficulties (vomiting, regurgitation, diarrhea) increased need for
non-nutritive sucking

Nursing Management
o Position infant on side to facilitate drainage of mucus
o Suction PRN to maintain patent airway
o Decrease environmental stimuli, swaddle for comfort
o Intake & output, daily weight
o Obtain meconium and/or urine for drug screening
 o Meds may include paregoric elixir, thorazine &Valium, methadone,
phenobarbital
o Pacifier for non-nutritive sucking
o Dont give Narcan to infant born to narcotic addict

INTENSIVE CARE FACILITIES FOR HIGH RISK NEWBORN

Rapid advances in our understanding of the pathophysiology of the neonate and
increased capacity to apply this knowledge have emphasized the need for appropriate
settings in which to care for the seriously ill infant. Advancements in electronics and
biochemistry, new methods for monitoring cardiorespiratory function, microtechniques for
biochemical determination from minute quantities of blood, noninvasive monitoring, and
new methods for assisted ventilation and conservation of body heat have made it possible
to effectively manage the newborn with serious illness.
Intensive care of the ill and immature newborn requires specialized knowledge and
skill in a number of areas. Much of the equipment used in the care of the critically ill adult is
unsuited to the singular needs of the very small infant; therefore equipment has been
modified to meet these needs. Examples of modifications include ventilators that deliver
small volumes of oxygen in the proper concentration and pressure, infusion pumps that
accurately deliver very small amounts, and radiant heat warmers that provide a constant
source of warmth and allow maximum access to the infant. Most important, advances in
intensive care have created a need for highly skilled personnel trained in the art of
neonatal intensive care.
The diversity of special care needs requires that the unit be arranged for graduated
care of the infant population. There should be adequate facilities and skilled personnel to
provide one-to-one nursing care for each seriously ill infant, as well as a means for
graduation to one-to-three or one-to-four nursing care in a quieter area where infants
require less intensive care until they are ready to be discharged to home. Family-centered
care and a relatively quiet environment are often difficult to provide in a busy neonatal
intensive care unit (NICU); therefore some units have developed step-down units and
single room units where high-risk infants may be observed by skilled staff. Such areas are
designed for family-centered care along with appropriate neuro developmental care.

ORGANIZATION OF SERVICES
The most efficient organization of services is a regionalized system of facilities
within a designated geographic area. Neonatal intensive care facilities may provide three
prescribed levels of care with special equipment, skilled personnel, and ancillary services
concentrated in a centralized institution (American Academy of Pediatrics and American
College of Obstetricians and Gynecologists, 2007):

Level I facilityProvides management of normal maternal and newborn care.

Level IIA facilityProvides a full range of maternity and newborn care and can
provide care to infants born at more than 32 weeks of gestation and weighing more
than 1500 g (3.3 lb) who are moderately ill with problems that are expected to
 resolve rapidly and who are not anticipated to need subspecialty care; or who are
convalescing after intensive care.
Level IIB facilityIn addition to the above, can provide mechanical ventilation for
up to 24 hours and can provide continuous positive airway pressure (CPAP).
Level III facilityNeonatal intensive care
o Level IIIA units provide care for infants with birth weight of more than 1000
g (2.2 lb) and gestational age of more than 28 weeks. Life support is limited
to conventional mechanical ventilation.
o Level IIIB units can provide care for extremely lowbirth weight (ELBW)
infants with technology including high frequency ventilation and inhaled
nitric oxide, on-site access to pediatric medical subspecialists, and advanced
diagnostic imaging and pediatric surgery available.
o Level IIIC units have the capabilities of a level IIIB NICU and, in addition, offer
extracorporeal membrane oxygenation (ECMO) and surgical repair of serious
congenital cardiac malformations.

TRANSPORTING HIGH-RISK NEWBORNS

When an at-risk infant is identified or anticipated, arrangements are made for care
in the intensive care facility. The uterus is the ideal transport unit for the infant with
anticipated difficulties; therefore, whenever possible, take the mother where special care is
available for her delivery.
Some infants develop difficulties after a seemingly normal pregnancy and
uncomplicated labor. Because it is impossible to always predict when infants will require
intensive care, a coordinated System is needed to ensure them an optimum opportunity for
survival. Each hospital that delivers infants should be able to provide for appropriate
neonatal stabilization and arrange for transport to a tertiary care facility.
The infant must be kept warm, be adequately oxygenated (including intubation if
indicated), have vital signs and oxygen saturation monitored, and, when indicated, receive
an intravenous (IV) infusion. The infant is transported in a specially designed incubator
unit that contains a complete life-support system and other emergency equipment that can
be carried by ambulance, van, plane, or helicopter.
The transport team may consist of one or more of the highly trained persons from
the NICU: a neonatologist (or a fellow in neonatology), a neonatal nurse practitioner, a
respiratory therapist, and one or more nurses. The professional assigned to accompany the
infant must be constantly alert to every change in the infants condition and able to
intervene appropriately.
The neonate who must be moved from one place to another within the hospital (e.g.,
to surgery, or from delivery room to nursery) is transported in an incubator or radiant
warmer and accompanied by the necessary personnel and equipment.
NURSING MANAGEMENT

COMMON NURSING DIAGNOSIS

Impaired Gas Exchange
Risk for Fluid Volume Deficit
Risk for impaired Nutrition
Risk for Infection
Risk for Altered Parenting
Diversional Activity Deficit
Risk for Disorganized Infant Behavior

MANAGEMENT OF HIGH RISK INFANT

PHYSICAL ASSESSMENT
THERMOREGULATION- need neutral thermal environment, use brown fat
CONSEQUENCES OF COLD STRESS- hypoxia, metabolic acidosis, hypoglycemia
GLUCOSE & CALCIUM
PROTECT FROM INFECTION
HYDRATION- IVF for calories, electrolytes & H2O
NUTRITION- no coordination of sucking until 32-34 weeks; not synchronized until
36-37 weeks; gag reflex not developed until 36 weeks
EARLY FEEDING- within 3-6 hours
BREAST FEEDING
GAVAGE FEEDING- <32 wks. or <1500g
SKIN CARE OF PREMATURE- increased sensitivity & fragile
MEDICATION - caution
DECREASE STRESS

DEVELOPMENTAL INTERVENTION
BEFORE 33 WEEKS- minimum stimulation
34-36 WEEKS- stimulate senses but dont tire out

ASSESSMENT OF NEWBORN
INTRODUCTION
At birth the newborn is given a cursory yet thorough assessment to determine any
apparent problems and identify those that demand immediate attention. This examination
 SIGN 0 1 2
is primarily concerned with the evaluation of cardiopulmonary and neurologic functions.
The assessment includes the assignment of an Apgar score and an evaluation for any
obvious congenital anomalies or evidence of neonatal distress. The infant is stabilized and
evaluated before being transported to the NICU for therapy and more extensive
assessment.
A thorough, systematic physical assessment is an essential component in the care of
the high-risk infant. Subtle changes in feeding behavior, activity, color, oxygen saturation
(Spo2), or vital signs often indicate an underlying problem. The preterm infant, especially
the ELBW infant, is not able to withstand prolonged physiologic stress and may die within
minutes of exhibiting abnormal symptoms if the underlying pathologic process is not
corrected. The alert nurse is aware of subtle changes and reacts promptly to implement
interventions that promote optimum function in the high-risk neonate.
The nurse notes changes in the infants status through ongoing observations of the
infants adaptation to the extrauterine environment. Observational assessments of the
high-risk infant are made according to the infants acuity (seriousness of condition); the
critically ill infant requires close observation and assessment of respiratory function,
including continuous pulse oximetry, electrolytes, and blood gases. Accurate
documentation of the infants status is an integral component of nursing care. With the aid
of continuous, sophisticated cardiopulmonary monitoring, nursing assessments and daily
care can be coordinated to allow for minimum handling of the infant (especially the very
lowbirth-weight [VLBW] or ELBW infant) to decrease the effects of environmental stress.

The newborn requires thorough skilled observation to ensure a satisfactory adjustment

to the extrauterine life. Physical assessment following delivery can be divided into 4
phases:
1. The initial assessment using an Apgar scoring system.
2. Transitional assessments during the periods of reactivity.
3. Assessment of gestational age.
4. Systematic physical examination.

INITIAL ASSESSMENT: APGAR SCORING

One significant assessment of the neonate is APGAR SCORING as described by DR
Virginia Apgar. Despite its limitations, it is a useful quantitative assessment of neonates
condition at birth especially for the respiratory, circulatory and neurological status. Five
objective criterias are evaluated at one minute and five minutes, after the neonates body is
completely born. The criterias are respiration, heart rate/minute, muscle tone, reflex
irritability and skin color. Each of these criteria is an index of neonates depression or lack
of it at birth and is given score of 0,1 or 2. The scores from each of the criteria are added to
determine the total score. The neonate is the best possible condition if the score is 10.
Scores of 7-10 indicate no difficulty in adjustment in extrauterine life. Scores of 4-6 signify
moderate difficulty and if the score is 3 or below, the neonate is in severe distress which
must be treated immediately.
 HEART RATE absent Slow <100 >100

RESPIRATORY absent Irregular slow weak Good strong cry

EFFORT cry

MUSCLE TONE limp Some flexion of Well flexed

extremities

REFLEX No response Grimace Cry. Sneeze

IRRITABILITY

COLOR Blue, pale Body pink extremities Completely pink

blue

Total score = 10
No depression : 7-10
Mild depression : 4-6
Severe depression : 0-3
TRANSITIONAL ASSESSMENT: PERIOD OF REACTIVITY-
During the initial 24 hours, changes in heart rate respiration, motor activity, color,
mucus production and bowel activity occurs in an orderly, predictable sequence that is
normal and indicates lack of stress.
First period of reactivity:
During the 1st 30 minutes the infant is very active, alert, cries vigorously, sucks the
fist greedily, and appears very interested in the environment. Neonates eyes are wide open
thus, is an excellent opportunity for mother, father and child to see each other.

Because the newborn has a vigorous suck this is the best time to begin breastfeeding.

Heart rate= 180/mt

Respiration= 80/mt
Bowel sounds are active.
Second stage of first reactive period:
Lasts for 2-4 hours.
Heart rate, respiration decreases.
Temperature continues to decrease. Undressing and bathing is avoided during this
time.
Mucus production decreases.
Urine and stool generally not passed.
Baby in a state of sleep and is calm.

Second period of reactivity:

Lasts for next 2-5 hours.
Heart rate and respirations increases.
Alert and responsive.
 Gastric, respiratory secretions increased.
Passage of meconium frequently.
After this stage is a stage of stabilization of physiologic systems.
ASSESSMENT OF GESTATIONAL AGE
One of the most satisfactory method for predicting mortality risks and providing
guidelines for the management of newborn is the classification of infants at birth by both
birth weight and the gestational age.
Appropriate for gestational age
Large for gestational age
Small for gestational age
Assessment of gestational age is mandatory for all neonates for further management.
Last menstrual period is important clue for calculation of gestational age, but it may not be
reliable in menstrual irregularities or mother may not remember the exact date. The
clinical assessment is more practically significant. Physical and neurological examinations
are done to detect the gestational maturity.
 Physical Preterm Transitional Term
Characteristic
s

Hair texture Wooly fuzzy and very Fine wooly, fuzzy Silky, black coarse and
and fine individual strands
distribution
on scalp

Skin texture Shiny oily plethoric, Less shiny, peripheral Pink, scanty lanugo and
and opacity plenty of lanugo, edema cyanosis, less lanugo and only large veins are
with visible veins and veins are only found on seen. Good elasticity or
venules on abdomen abdomen turgor

Breast nodule Breast tissue less than Breast tissue 5-10 mm More than 10mm
and nipple 5 mm on one or both diameter
Nipple present but not
formulation sides.
raised Breast tissue and
No nipple present nipple raised above
skin level

Ear cartilage Pinna feels soft with no Some cartilage present Pinna is firm with
cartilage and no recoil and some recoil definite cartilage and
instant recoil

Planter Faint red marks over Creases seen over Entire sole covered
creases anterior part of sole or anterior 3 to of sole with deep creases
1/

may be absent

Genitalia Scrotum small with no Scrotum with some Atleast one testis
[male] or few rugae and light rugae and testis in the descends in the
pigmentation. Testis inguinal canal scrotum. Prominent
usually not descend or rugae and deep
in inguinal canal pigmentation

Genitalia Labia majora widely Labia majora partially Labia majora

[female] separated with cover over the completely cover the
prominent labia minora labiaminora labia minora and
and clitoris clitoris
 Assessment of maturity of the neonates is fairly reliable on the basis of physical
characteristics. But they are of limited value to assess the gestational age in less than 36
weeks of maturity. The neurological characteristics are more reliable for the precise
assessment of maturity.
The neurological assessment is performed based on four fundamental observations, i.e.
muscle tone, joint mobility, certain automatic reflexes and fundus examination.
The muscle tone of the newborn baby is assessed by three parameters, i.e. posture or
attitude, passive tone [popliteal angle]and scarf sign and active tone [traction response and
recoil]
The joint mobility is less in preterm babies. A term baby has more flexible and relaxed
joint. The degree of flexion at ankle and wrist [square-window] is limited due to stiffness of
joints in early gestation.
Certain auto9matic reflexes like moro reflex, papillary response to light, blink response
to glabellar tap, grasp response, neck flexors, rooting reflex with coordinated suckling
efforts are assessed to detect the specific age of gestational maturity based on appearance
of these reflexes.
The fundamental examination for disappearance of anterior vascular capsule of lens is
done to assess the gestational age. In infants less than 28 weeks, the anterior capsule is
completely vascularized and after 34 weeks of gestational life, the vessels are almost
atrophied. This examination is difficult due to non-co-operation and photophobia of the
neonate.
With the scoring system of the neurological assessment the accurate estimation of
gestational age can be done. New Ballard score is widely used. Neuromuscular maturity is
assessed by the test like posture, square window [wrist], arm recoil, popliteal angle, scarf
sign and heel to ear, using the new Ballard scoring system. Physical maturity is assessed
with this system by the characteristics like skin, lanugo, planter surface, breast, eye/ear
and genitals.

TESTS USED IN ASSESSMENT OF GESTATIONAL AGE:

POSTURE:
With infant quite and in supine position, observe degree of flexion in arms and legs.
Muscle tone and degree of flexion increase with maturity. Full flexion of the arms and
legs=4
SQUARE WINDOW:
With thumb supporting back of arm below wrist, apply gentle pressure with index
finger and third fingers on dorsum of hand without rotating infants wrist. Measure angle
between base of thumb and forearm. Full flexion (hand lies flat on ventral surface of
forearm)=4
ARM RECOIL:
With infant supine, fully flex both forearms on upper arms, hold for 5 seconds; pull
down on hands to fully extend and rapidly release arms. Observe rapidity and intensity of
recoil to a state of flexion. A brisk return to full flexion=4
POPLITEAL ANGLE:
With infant supine and pelvis flat on a firm surface, flex lower leg on thigh and then
flex thigh on abdomen. While holding knee with thumb and index finger, extend lower leg
with index finger of other hand. Measure degree of angle behind knee (popliteal angle). An
angle of less than 90 degrees=5
SCARF SIGN:
With infant supine, support head in midline with one hand; use other hand to pull
infants arm across the shoulder so that infants hand touches shou7lder. Determine
location of elbow in relation to midline. Elbow does not reach midline=4
HEEL TO EAR:
With infant supine and pelvis flat on a firm surface, pull foot as far as possible up
toward ear on same side. Measure distance of foot from ear and degree of knee flexion
(same as popliteal angle). Knees flexed with a popliteal angle of less than 10 degrees =4
NEW BALLARD SCORING SYSTEM
Neuromuscular maturity is assessed by:
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear

SUBSEQUENT OR FOLLOW-UP ASSESSMENT IN THE NEONATAL PERIOD

Subsequent assessment is usually done, in institutional delivery, on the first day of
birth, i.e. within 24 hours and within the time of discharge. Daily clinical evaluation should
be done, between first day examination and the day of discharge. Daily clinical evaluation
should be done, between first day examination and the day of discharge. But daily detailed
examination is not necessary because it may introduce infections.
First day examinations should include the followings:
General measurements:
 For full term infant average head circumference = 33 and 33.5cm.
Chest circumference= 30.5-33cm.
Head to heel length= 48-53 cm
Body weight= 2700-4000g.
Vital signs:
Axillary temperature: 36.5 to 37.6 C( 97.7- 99.7F)
Pulse: 120-140/mt
Respirations: 30-60/mt
Blood pressure: 65/41 mm of Hg
General appearance:
Posture- complete flexion
Behaviour- degree of alertness, drowsiness or irritability to be noted.
PHYSICAL ASSESSMENT:
Skin: Velvetty, smooth and puffy, color depending on the racial and family background.
Head: Check the contour. Palpate fontanelles and sutures noting size , shape, molding, or
abnormal closure.check for any cephal hematoma and caput succedaneum. Assess the
degree of head control
Eyes: Edematous lids, purulent discharge from eyes shortly after birth is abnormal. Sclera
should be white and clear.
Ears: Note the position , structure and auditory function. Top of the pinna should lie in
horizontal plane to the outer canthus of eye. Observe startle reflex.
Nose: Sneezing and thin white mucus common.
Mouth and throat:
Size: small mouth found in trisomy 18 and 21; corners of mouth turn down (fish
mouth) in fetal alcohol syndrome.
Mucous membranes should be pink.
Palate examination (hard and soft palate )for closure.
Size of tongue: in relation to mouth normally does not extend much past the margin of
gums? Excessively large tongue seen in congenital anomalies, such as cretinism and
trisomy 21.
Teeth: pre-deciduous teeth are found on rare occasions; if they interfere with feeding,
they may be removed.
Epstein's pearls: small white nodules found on sides of hard palate (commonly
mistaken for teeth); regress in a few weeks.
Frenulum linguae: thin ridge of tissue running from base of tongue along
undersurface to tip of tongue, formerly believed to cause tongue-tie; no treatment
necessary. True congenital ankyloglossia (tongue-tie) is rare.
Infections : thrush, caused by Candida albicans, may appear as white patches on
tongue and/or insides of
cheeks that do not wash away with fluids; treated with nystatin suspension.
Neck
Examine the following:
Mobility : infant can move head from side to side; palpate for lymph nodes; palpate
clavicle for fractures, especially after a difficult delivery.
 Torticollis: appears as a spasmodic, one-sided contraction of neck muscles;
generally from hematoma of sternocleidomastoid muscle; usually no treatment
required.
Excessive skin folds may be associated with congenital abnormalities such as
trisomy 21.
Stiffness and hyperextension may be caused by trauma or infection.
Clavicle for intactness.
Observe for masses such as cystic hygroma which is soft and usually seen laterally
or over the clavicle.
Chest
Circumference and symmetry : average circumference is 12 to 13 inches (30 to 33
cm), approximately 2 cm smaller than head circumference.
Breast.
Engorgement may occur at day 3 because of withdrawal of maternal
hormones, especially estrogen; no treatment required. Regresses in 2 weeks.
Nipples and areola less formed and pronounced in preterm infants.
Respiratory System
Rate normally between 40 to 60 breaths/minute; influenced by sleep-wake status,
when last fed, drugs taken by mother, and room temperature.
Rhythm respirations may be shallow with irregular rhythm.
Breath sounds,determined by auscultation.
Cardiovascular System
Rate:normal between 110 to 160 bpm (80 to 110 normal with deep sleep);
influenced by behavioral state, environmental temperature, medication; take apical
count for 1 minute.
Rhythm:common to find periods of deceleration followed by periods of acceleration.
Heart sounds,second sound higher in pitch and sharper than first; third and fourth
sounds rarely heard; murmurs common, majority are transitory and benign.
Pulses,examine equality and strength of brachial, radial, pedal, and femoral pulses;
lack of femoral pulses indicative of inadequate aortic blood flow.
Cyanosis,examine for cyanosis. Acrocyanosis of distal extremities is common; record
location of any cyanosis, color changes with time, and when crying.
Blood pressure,neonates who weigh more than 3 kg have systolic blood pressure
between 60 to 80 mm Hg; diastolic, between 35 and 55 mm Hg. Blood pressure is
usually higher in the lower extremities than in the upper extremities. Blood
pressure assessment may not be conducted routinely on healthy neonates.
Measurement of blood pressure is essential for infants who show signs of distress,
are premature, or are suspected of having a cardiac anomaly.
Abdomen
Shape,cylindrical, protrudes slightly, moves synchronously with chest in respiration.
Distension may be caused by bowel obstruction, organ enlargement, or infection.
Palpate abdomen for masses; gap between rectus muscles is common; palpate liver
and spleen.
Auscultate abdomen in all four quadrants for bowel sounds; usually bowel sounds
occur an hour after delivery.
Kidneys palpate kidneys for size and shape.
 Umbilical cord
Normally contains two arteries, one vein; single artery sometimes associated
with renal and other congenital abnormalities.
Signs of infection around insertion into abdominal wall-redness, discharge.
Meconium staining,associated with intrauterine compromise or
postmaturity.
By 24 hours, becomes yellowish brown; dries and falls off in approximately
10 to 14 days.
Umbilical hernia,defect in abdominal wall.
Genitalia
Female

Labia majora cover labia minora and clitoris in full-term female infants.
Hymenal tag (tissue) may protrude from vagina,regresses within several weeks.
Vaginal discharge,white mucous discharge common; pink-tinged mucous discharge
(pseudomenstruation) may be present because of the drop in maternal hormones; no
treatment necessary.
Male
Full-term,testes in scrotal sac; scrotal sac appears markedly wrinkled due to rugae.
Edema may be present in scrotal sac if the infant was born in breech presentation; a
frank collection of fluid in the scrotal sac is a hydrocele,regresses in approximately a
month.
Examine glans penis for urethral opening,normally central; opening ventral
(hypospadias); opening dorsally (epispadias); abnormally adherent foreskin
(phimosis).
o Check for patent anus,infant should pass stool within 24 hours after delivery.
If passed meconium in utero, patent anus has been established.
Back
Examine spinal column for normal curvature, closure, and pilonidal dimple or sinus;
also for tufts of hair or skin disruptions that would indicate possible spina bifida.
Examine anal area for anal opening, response of anal sphincter, fissures.
Musculoskeletal System
Examine extremities for fractures, paralysis, range of motion, irregular position.
Examine fingers and toes for number and separation: extra digits, polydactyly; fused
digits, syndactyly.
Examine hips for dislocation,with the infant in supine position, flex knees and
abduct hips to side and down to table surface; clicking sound indicates dislocation
(Ortolani's sign).
Asymmetrical gluteal folds also indicate congenital hip dislocation.
Examine feet for structural and positional deformities, ie, club foot (talipes
equinovarus) or metatarsus adductus (inward turning of the foot).
Neurologic System
Neurologic mechanisms are immature anatomically and physiologically; as a result,
uncoordinated movements, labile temperature regulation, and lack of control over
musculature are characteristic of the infant.
Examine muscle tone, head control, and reflexes.
 Two types of reflexes are present in the neonate:
Protective in nature (blink, cough, sneeze, gag),remain throughout life.
Primitive in nature (rooting/sucking, moro, startle, tonic neck, stepping, and
palmar/plantar grasp),either disappear within months or become highly developed
and voluntary (sucking and grasping)
BEHAVIORAL ASSESSMENT
Response to Stimulation
Neonates exhibit predictable, directed responses in social interactions with
nurturing adults or in response to attractive auditory or visual stimuli.
Sleeping Pattern
Length of sleep cycles (REM, active and quiet sleep) changes with maturation of the
central nervous system (CNS).
Quiet sleep should increase with time in relation to REM sleep.
Neonates usually sleep 20 hours per day.

Feeding Pattern
Most neonates feeds 6 to 8 times per day with 2 to 4 hours between feedings;
establish fairly regular feeding patterns in approximately 2 weeks.
Caloric requirements are high,110 to 130 calories/kg of body weight daily.
Most digestive enzymes are present at birth.
Imperfect control of cardiac and pyloric sphincters; immaturity results in
regurgitation.
Pattern of Elimination
Stool
o Meconium is usually passed in 24 hours.
o Passage of meconium (tarry green-black stools) continues for 48 hours,
followed by transitional stools (combination of meconium and yellow or milk
stools). Milk stools (yellow) are passed by day 5.
o Neonate has up to six stools per day in the first weeks after birth.
Voiding
o Neonate voids within first 24 hours.
o After first few days, infant voids from 10 to 15 times per day.
Temperature Regulation
Infant's body responds readily to changes in environmental temperature.
Heat loss at birth may occur through evaporation, convection, conduction, and
radiation.
Physiologic mechanisms to avoid heat loss include:
o Vasoconstriction.
o Nonshivering thermogenesis elicited by sympathetic nervous system in
response to decreased temperature.

REFLEXES OF NEWBORN
PRIMITIVE REFLEX
Primitive reflexes are reflex actions originating in the central nervous system
that are exhibited by normal infants but not neurologically intact adults, in response to
particular stimuli. These reflexes disappear or are inhibited by the frontal lobes as a child
moves through normal child development. These primitive reflexes are also called
infantile, infant or newborn reflexes.
ADAPTIVE VALUE OF REFLEXES
Reflexes vary in utility. Some have a survival value. A perfect example would be
the rooting reflex, which helps a breastfed infant find the mother's nipple. Babies display it
only when hungry and touched by another person, not when they touch themselves. There
are a few reflexes that probably helped babies survive during human evolutionary past like
the Moro reflex.
Other reflexes such as sucking and grabbing help establish gratifying interaction
between parents and infants. They can encourage a parent to respond lovingly and feed
more competently. They can also help parents comfort their infant because they allow the
baby to control distress and the amount of stimulation they receive.

ROOTING REFLEX
The rooting reflex is present at birth: it assists in breastfeeding, disappearing at
around four months of age as it gradually comes under voluntary control.
A newborn infant will turn his head toward anything that strokes his cheek or
mouth, searching for the object by moving his head in steadily decreasing arcs until the
object is found. After becoming used to responding in this way (if breastfed, approximately
three weeks after birth), the infant will move directly to the object without searching.

SUCKING REFLEX
The sucking reflex is common to all mammals and is present at birth. It is linked
with the rooting reflex and breastfeeding, and causes the child to instinctively suck at
anything that touches the roof of their mouth and suddenly starts to suck simulating the
way they naturally eat. There are two stages to the action:
Expression: activated when the nipple is placed between a child's lips and touches their
palate. They will instinctively press it between their tongue and palate to draw out the
milk.
Milking: The tongue moves from areola to nipple, coaxing milk from the mother to be
swallowed by the child.
GRASP
This reflex is shown by placing finger or an object into baby's open palm, which will
cause a reflex grasp or grip. If it is tried to pull away, the grip will get even strong. The
palmar and plantar grasp usually disappears by 5-6 months and 9-12 months respectively.

PLANTAR REFLEX
A plantar reflex is a normal reflex that involves plantar flexion of the foot (toes
move away from the shin, and curl down.

BABINSKI REFLEX
 An infant demonstrating the Babinski reflex: he opens his mouth when pressure is
applied to both palms (8 seconds).
The Babinski reflex occurs in newborn babies, and describes varying responses to
the application of pressure to both palms. Infants may display head flexion, head rotation
or opening of the mouth, or a combination of these responses. Smaller, premature infants
are more susceptible to the reflex.
MORO REFLEX
Also called the startle reflex, the Moro is usually triggered if baby is startled by a
loud noise or if his head falls backward or quickly changes position. Baby's response to the
moro will include spreading his arms and legs out widely and extending his neck. He will
then quickly bring his arms back together and cry. The moro reflex is usually present at
birth and disappears by 3-6 months.

STARTLE REFLEX

The Moro reflex in a four-day-old infant: 1) the reflex is initiated by pulling the
infant up from the floor and then releasing him; 2) he spreads his arms 3) he pulls his arms
in; 4) he cries (10 seconds)

MORO REFLEX
WALKING/ STEPPING REFLEX
The walking or stepping reflex is present at birth; though infants this young can not
support their own weight, when the soles of their feet touch a flat surface they will attempt
to 'walk' by placing one foot in front of the other. This reflex disappears at 6 weeks as an
automatic response and reappears as a voluntary behavior at around eight months to a
year old

WALKING/STEPPING REFLEX
TONIC NECK REFLEX
The tonic neck reflex, also known as asymmetric tonic neck reflex or 'fencing
posture' is present at one month of age and disappears at around four months. When the
child's head is turned to the side, the arm on that side will straighten and the opposite arm
will bend (sometimes the motion will be very subtle or slight). According to researchers,
the tonic neck reflex is a precursor to the hand/eye coordination of the infant. It also
prepares the infant for voluntary reaching.

TONIC NECK REFLEX

Opposite reaction Tonic Neck Reflex
A postural reaction, the asymmetric tonic neck reflex, or fencer response, is
present at birth. To elicit this reflex, while your baby is lying on his back, turn his head to
one side, which should cause the arm and leg on the side that he is looking toward to
extend or straighten, while his other arm and leg will flex. This reflex usually disappears by
4-9 months.
GALANT REFLEX
 If your baby is on his stomach and you stroke neck to the spinal cord
(paravertebral area) on his middle to lower back, it will cause his back to curve towards the
side that you are stroking. This reflex is present at birth and disappears by 3-6 months. If
the reflex persists past six months of age, it is a sign of pathology. The reflex is named after
the Russian neurologist Johann Susman Galant.

SWIMMING REFLEX
An infant placed face down in a pool of water will begin to paddle and kick in a
swimming motion. The reflex disappears between 46 months. Its survival function is to
help the child stay alive if it is drowning so a caregiver has more time to save it.
DOLLS EYE REFLEX
Eyes open on coming to sitting (Like a Doll's) Head initially lags Baby uses
shoulders to right head position
PROTECTIVE REFLEX
1. Soft cloth is placed over the babies eyes and nose
2. Baby arches head and turns head side to side
3. Brings both hands to face to swipe cloth away
CRAWLING REFLEX
Newborn placed on abdomen
Baby flexes legs under him and starts to craw
PARACHUTE RESPONSE
This is a protective response that protects infant if he falls. Beginning at about 5-6
months, if an infant falls, he will extend his arms to try and 'catch' himself.
PROPPING
Beginning at different ages, the propping responses help child learn to sit. The first
is the anterior propping response, which begins at 4-5 months, and involves infant
extending his arms when he is held in a sitting position, allowing him to assume a tripod
position.
Next, lateral propping, appearing at 6-7 months, causes him to extend his arm to the
side if he is tilted.
Lastly, posterior propping, causing him to extend his arms backwards if he is titled
backward.
DAILY OBSERVATION OF NEONATES:
Neonates should be observed daily during hospital stay. Detailed examination is not
necessary but mother and baby should be approached two times daily and informations
should be collected from the mother (or caretaker) about the feeding behavior, vomiting,
passage of stool and urine, sleep and presence of any problems. The neonates should also
be assessed for hypothermia, respiratory distress, jaundice and superficial infections like
conjunctivitis, umbilical sepsis, oral thrush and skin infection.
The neonates should be monitored for the danger signs. Presence of these features
indicates special attention, reevaluation and early interventions.
The danger signs are:
Poor feeding, sucking and swallowing reflex.
Cold to touch or having rise in body temperature
Poor activity and poor response to stimulation
 Excessive crying and irritability
Rapid respiration, more than 60 per minutes and presence of chest retractions
Blue discoloration of lips or tongue (central cyanosis)
Drooling of saliva or chocking during feeding or frothiness
Labored respiration or absence of respiration
Jaundice appears within 24 hours one extending to palms or soles
No urine within 48 hours and no meconium within 24 hours
Convulsions or abnormal movements
Bleeding from any site
Umbilical discharge
Superficial infections (pyoderma, abscess, oral thrush, conjunctivitis)
Diarrhea, vomiting and abdominal distension.

NEONATAL INTENSIVE CARE UNIT GOALS AND OBJECTIVES

GOAL 1: Understand the pediatricians role in reducing morbidity in high risk pregnancies
and complications of childbirth.

OBJECTIVES
Describe general principles about:
o Basic vital statistics that apply to newborns (neonatal, perinatal
mortality,etc.)
o Tests commonly used by obstetricians to measure fetal well-being.
o Prenatal services available in ones region.
o Prenatal visit in the pediatricians office.
o Neonatal transport systems
o Effective intervention programs for teens and other high risk mothers

For each of the following prenatal and perinatal complications

o Describe the pediatricians role in assessment and management.
o Recognize potential adverse outcomes for the fetus/neonate

List of complications:
o Maternal infections/exposure to infections during pregnancy
o Fetal exposure to harmful substances (ETOH, TOB, street drugs, medications,
environment toxins)
o Maternal insulin-dependent diabetes and pregnancy-induced glucose
intolerance
o Premature labor, premature ruptured membranes
o Complications of anesthesia and common delivery practices (Cesaerean
section, vacuum, forceps, epidural, induction of labor)
o Fetal distress during delivery
o Postpartum maternal fever/infection
o History of maternal GBS colonization/treatment
 o Multiple gestation
o Placental abnormalities
o Pre-eclampsia, eclampsia PL 2,3l. Chorioamnionitis
o Polyhydramnios
o Oligohydramnios

Discuss the pediatricians role in reducing fetal and neonatal morbidity/mortality

ihis/her own community.

GOAL 2: Understand how to resuscitate and stabilize a critically ill neonate.

OBJECTIVES
Describe the steps in resuscitation and stabilization, including equipment needed.
Demonstrate efficient and effective resuscitation in mock codes and under stress of
actual codes.
Formulate a differential diagnosis for serious symptoms presenting during transfer
to the NICU or in the NICU immediately after resuscitation.

GOAL 3: Understand how to evaluate and manage common signs and symptoms of disease
in high risk newborns.

OBJECTIVES
For each of the signs and symptoms below:
1. Perform an appropriate assessment (H&P, Initial diagnostic studies).
2. Formulate a differential diagnosis with appropriate prioritization
3. Describe indications for admission or referral to Levels I, II, and III nurseries.
4. Describe stabilization procedures to prepare for transfer
5. Formulate and carry out a plan for continuing assessment and management.

List of Signs and Symptoms (NICU)

General:
Intrauterine growth failure
Large for gestational age
Hypothermia
Hyperthermia,
Prematurity
Feeding problems
Poor postnatal weight gain
Lethargy/irritability/jitteriness,
History of maternal infection or exposure,
Dehydration.

Cardiorespiratory
Respiratory distress
Cyanosis
 Apnea
Bradycardia
Heart murmur
Hypotension
Hypotension
Hypovolemia
Poor pulses
Shock

Dermatologic:
Common skin rashes/conditions,
Birthmarks
Hyper and hypopigmented lesions
Discharge and/or inflammation of the umbilicus
Proper skin care for premature infants
Vesicles.

Gastro Intestinal/Surgical:
Feeding intolerance
Vomiting,
Bloody stools
Distended abdomen,
Hepatosplenomegaly
Abdominal mass
Failure to pass stool
Diarrhea.

Genetic/Metabolic:
Metabolic derangements,
Hypoglycemia
Hypercalcemia
Hypocalcemia,
Hypokalemia
Hyperkalemia
Apparent congenital defect or dysmorphic syndrome.

Hematologic:
Jaundice in a premature, term or seriously ill neonate,
Petechiae
Anemia,
Polycythemia
Abnormal bleeding,
Thrombocytopenia
Neutropenia.
Musculoskeletal
Birth trauma related fractures and soft tissue injuries
Dislocations
Birth defects and deformities.
Neurologic
Hypotonia
Hypertonia
Seizures,
Lethargy
Early signs of neurologic impairment,
Microcephaly, macrocephaly
Spina bifida
Birthtrauma related nerve damage.

Parental Stress/Dysfunction
Poor attachment,
Postpartum depression
Anxiety disorders
Teen parent
Substance abuse
Child abuse and
Neglect.

Renal/Urologic
Edema
Decreased urine output
Abnormal genitalia
Renal mass
Hematuria,
Urinary retention
Inguinal hernia.

Ophthalmologic
Abnormal red reflex
Eye anomaly

GOAL 4: Understand how to manage, under the supervision of a neonatologist, common

diagnoses in infants in a Level II or III nursery.

OBJECTIVES
For each of the following common diagnoses in the list below; be able to
o Describe the pathophysiologic basis of the disease.
o Describe the initial assessment plans.
o Discuss key principles of the NICU management plan.
o Explain when to use consultants.
o Explain the role of the primary care provider.
List of Common Diagnoses in this Setting (NICU)
Pulmonary disorders: Hyaline membrane disease, transient tachypnea of the newborn,
meconium aspiration, amniotic fluid or blood aspiration, persistent pulmonary
hypertension, pneumonia, pneumothorax, bronchopulmonary dysplasia, atelectasis.

Cardiac conditions: Congenital heart disease (cyanotic and acyanotic, obstructive lesions,
single ventricle), patent ductus arteriosus, congestive heart failure, SVT, complete heart
block.

Genetic, endocrine disorders: Infant of diabetic mother, common chromosomal

anomalies, congenital adrenal hyperplasia, hypo and hyperthyroidism.

GI/nutrition: Feeding plans and nutritional management of high risk neonates or those
with special needs, breast feeding support for mothers and infants with special needs,
hepatitis, gastrointestinal reflux, meconium plug, malrotation, Hirschprungs, necrotizing
enterocolitis, short gut syndrome, gastroesophageal reflux.

Hematologic conditions: Indications for phototherapy, anemia, polycythemia, transfusion

of blood products, exchange transfusions in the premature/term or ill neonate,
erythroblastosis fetalis/hydrops fetalis, coagulopathy, hemophilia, Vitamin K
prophylaxis/deficiency.

Infectious disease: Intrauterine viral infections, Group B Streptococcal infections, neonatal

sepsis and meningitis, herpes simplex; infant of HIV infected mothers, neonatal hepatitis,
syphilis; nosocomial infections in the NICU, central line infections, immunization of the
premature neonate, isolation procedures for contagious diseases in mother/infant,
indications for RSV prophylaxis.

Neurologic disorders: Hypoxic-ischemic encephalopathy, intraventricular hemorrhage,

hearing loss in high risk newborns, drug withdrawal, seizures, hydrocephalus, spina bifida,
CNS anomalies.

Surgery: (assess and participate in management under supervision of or collaboration

with pediatric surgeon) Necrotizing enterocolitis, short gut syndrome, intestinal
perforation, intestinal obstruction, diaphragmatic hernia, malrotation, esophageal atresia
and tracheoesophageal fistula, intestinal atresia, meconium ileus, meconium plug
syndrome, gastroschisis, omphalocele, imperforate anus, pre-op and post-op care.
Eye disorders: retinopathy of prematurity, cataracts and eye anomalies
Miscellaneous: complications of umbilical catheterization

GOAL 5: Understand how to use and interpret laboratory and imaging studies unique to
the NICU stetting.
OBJECTIVES
Order and interpret laboratory and imaging studies appropriate for NICU patients.
Explain indications, limitations, and gestational-age norms for the following which
may have specific application to neonatal care:
o Serologic and other studies for transplacental infections
o Direct and indirect Coombs test
o Neonatal drug screening
o Neuro ultrasound
o Abdominal x-rays for placement of umbilical catheter, bowel gas pattern,
evidence of NEC
o Chest x-rays for endotracheal tube placement, heart size and vascularity,
deep line placement

GOAL 6: Understand the application of the physiologic monitoring and special technology
applied to the care of the fetus and newborn

OBJECTIVES
For each of the following, which are commonlyused by pediatricians, discuss
indications and limitations and demonstrate proper use/instruction in how to use:
o Physiologic monitoring of temperature, pulse, respiration, blood pressure
o Phototherapy
o Pulse oximetry
o Umbilical arterial and venous catheterization
o Endotracheal intubation
o Thoracentesis
o Chest tube placement
o Electric and manual breast pumps
From each of the following techniques and procedures used by obstetricians,
perinatalologists, and neonatologists, describe key indications, limitations, normal
and frequently encountered abnormal findings, and common complications for the
fetus/infant:
o Fetal ultrasound for size and anatomy
o Fetal heart rate monitors
o Scalp and cord blood sampling
o Surfactant therapy
o ECMO/Nitric oxide therapy
o Amniocentesis
o Biophysical profile/stress testing
o Intrauterine transfusions/PUBS
o Chorionic villus sampling
o Exchange transfusion
o Central hyperalimentation
 Discuss in general terms, home medical equipment and services needed for oxygen
dependent and technology dependent graduates of the NICU.

GOAL 7: Develop a logical and effective approach to the assessment and daily management
of seriously ill neonates and their families, under the guidance of a neonatologist, using
decision-making and problem solving skills.

OBJECTIVES
Apply principles of decision-making and problem solving to care in the NICU.
Seek information as needed and apply this knowledge appropriately using evidence
baseproblem solving.
Recognize the limits of ones own knowledge, skill, and tolerance of stress; know
when to afor help, how to contact consultants and where to find basic information.
Develop a comprehensive problem list with appropriate and accurate prioritization
for action.

GOAL 8: Understand how to function effectively as part of an interdisciplinary team

member in the NICU.

OBJECTIVES
Communicate and work effectively with all members of the healthcare team
(residents, attending, consultants, nurses, nurse specialists, lactation consultants,
nutritionist, pharmacists, respiratory therapist, social workers, discharge
coordinators, referring physicians and ancillary Staff).
Communicate effectively with parents of critically ill patients and highly stressed
families.
Discuss role of primary care physician in the long term management of infants
admitted to the NICU.
Discuss the role of managed care case manager, work with these individuals to
optimize healthcare outcomes.

GOAL 9: Understand how to provide comprehensive and supportive care to the NICU
infant and their family.

OBJECTIVES
Serve effectively as an advocate and case manager for patients with multiple
problems or chronic illnesses.
Work with discharge coordinator to develop discharge plans which facilitate the
familys transition to home care, including adequate follow-up and appropriate use
of community services.
Demonstrate sensitivity and skills in dealing with death and dying in the NICU
setting.
Consistently listen carefully to concerns of families and provide appropriate
information and support.
 Provide counseling and support for breast feeding of premature and critically ill
infants, including maintenance of mothers milk supply when the infant cannot
suckle.
Provide responsible communication with the neonates primary care physician
during the hospital stay and in discharge planning.
Identify problems and risk factors in the infant or family and make appropriate
interventions and/or referrals.

GOAL 10: Become familiar with ethical and medical-legal consideration in the care of
critically ill newborns.

OBJECTIVES
Discuss concepts of futility, withdrawal and withholding care.
Describe hospital policy on Allow Natural Death orders.
Identify situations warranting consultation with the hospital ethics committee.
Complete a death certificate appropriately.

GOAL 11: Understand key aspects of cost control and mechanisms for payment in the
NICU setting

OBJECTIVES
Be sensitive to the burden of costs on families and refer for social services as
indicated.
Use consultants and other resources appropriately during NICU stay and in
discharge planning.
Demonstrate awareness of costs and cost control in NICU care.
Explain principles of typical coverage by local insurance plan, Medical, and other
state and federal subsidies for the care of high risk neonates.

GOAL 12: Understand how to maintain accurate, timely and legally appropriate medical
records in the critical care setting of the NICU.

OBJECTIVES
Ensure that initial history and physical examination records include appropriate
history, exam appropriate for the infants condition, record of procedures in
delivery room and since admission; problem list assessment and plan.
Maintain daily timed notes, with updates as necessary, clearly documenting the
patients progress and details of the on-going evaluation and plan.
Ensure discharge summary is timely and concise, with clear documentation of
discharge plans and follow up appointments.

CONCLUSION
Some newborns are considered high risk. This means that a newborn has a greater
chance of complications because of conditions that occur during fetal development,
pregnancy conditions of the mother, or problems that may occur during labor and birth.
 Some complications are unexpected and may occur without warning. Other times,
there are certain risk factors that make problems more likely.
Fortunately, advances in technology have helped improve the care of sick newborns.
Under the care of specialized physicians and other healthcare providers, babies have much
greater chances for surviving and getting better today than ever before.