High risk infant new

High risk infant

1. HIGH RISK NEWBORN Soumya Ranjan Parida

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

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

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

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

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

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

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

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

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

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

12. POST TERM NEWBORN CHARACTERISTICS Newborn emaciated ▪ dry peeling skin Meconium stained ▪ Creases cover soles Hair and nails long ▪ L imited vernix & lanugo

13. Low Birth Weight Newborn: ● Preterm ● IUGR Term preterm Symmetric A Symmetric

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

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

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

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

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

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

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

21. INFANT OF DIABETIC MOTHER

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

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

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

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

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

27. FOLLOW UP OF HIGH RISK INFANT

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

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

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

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

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

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

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

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