The document is about high risk infants and babys

It's a medical detailed document on infants and their infections

1. HIGH RISK INFANT

3. Definitions
•High risk neonate is 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 & adjustment
to extrauterine existence

4. High risk period
•This encompasses human growth &
development from time of viability - the
gestational age at which survival outside
the uterus is believed to be possible, or as
early as 23 wks of gestation to 28 days
after birth

5. Identification of At-risk
Newborn
1.Low socioeconomic level of the mother
2.Limited or no prenatal care
3.Exposure to environmental dangers
4.Preexisting maternal conditions
5.Maternal factors such as age or parity
6.Medical conditions related to pregnancy
7.Pregnancy complications

6. Classification of high risk
infants (weight)
•Low birth weight infants (LBW) – an
infant whose birth weight is less than 2500gm
(5.5 pounds) regardless of gestation age
•Very low birth weight infant (VLBW) –
an infant with birth weight less than 1500gm
•Extremely low birth weight (ELBW) –
an infant with birth weight less than 1000gm

7. Cont…
•Appropriate for gestational age infant
– infant whose weight falls between 10
th

and 90
th
percentiles on intrauterine growth
curves
•Small for date/ gestation (SGA) – an
infant whose rate of intrauterine growth was
slowed & whose birth weight falls below the
10
th
percentile on intrauterine growth
curves

8. Cont…
•Intrauterine growth restriction –
infants whose intrauterine growth is
restricted
•Large for gestation age (LGA) – an
infant whose birth weight falls above the
90
th
percentile on intrauterine growth
charts.

9. Intrauterine Growth Curve

10. Classification according to
gestational age
•Premature (preterm) infant – an infant born
before completion of 37 weeks of gestation
regardless of birth weight
•Full term infant – an infant born between the
beginning of 37 wks and the completion of the
42wks gestation, regardless of birth weight
•Post mature (postterm) infant – an infant born
after 42 wks of gestation age, regardless of birth
weight

11. Types of Low Birth Weight
•The neonate can be LBW because of;-
–Preterm or premature (not completed 37wks
gestation). Baby likely to have low weight as
delivery takes place prematurely
–Small for Gestation Age (SGA)/ IUGR. This
condition is similar to malnutrition. Here,
gestation may be full term or preterm, but the
baby is undernourished, undersized &
therefore, LBW

12. Causes of LBW??

13. Causes of Prematurity
•Unknown
•Maternal factors; malnutrition, chronic diseases
(heart diseases, renal disease& liver dse),
malaria, Tobacco use
•Pregnancy related factors; hypertension,
Anemia, abruption placenta or placenta previa,
multiple pregnancy, incompetent cervix, PROM,
chorioamnionitis & polyhydramnios
•Fetal factors; chromosomal abnormalities,
intrauterine infections, anatomic abnormalities

14. Cont…
•Frequent pregnancies
•Low maternal weight (mothers with a
weight < 40kg & a height of < 145cm often
give birth to LBW babies
•Teenage pregnancy
•Previous preterm baby
•Cervical incompetence
•Induced premature labor

15. How to recognize Preterm
& SGA Infant

16. Diagnostic evaluation - I
•Date of LMP
•Physical features (Premature neonate)
–Very small
–Skin is bright pink, smooth, shiny with small blood
vessels clearly visible underneath the thin epidermis
–Fine lanugo hair in abundance on the body but is
sparse on the head
–External ear or the pinna is soft & devoid of cartilage
hence does not recoil back promptly on being folded
–Scrotum does not have rugae & testes are not
descended

17. Cont…
•Labia are widely separated, not covering
the minora resulting in prominent
appearance of the clitoris
•Soles & palms have minimal creases
resulting in smooth appearance
•Bones of skull & ribs feel soft

18. Cont…
•Extremities maintain an attitude of extension &
remain in any position in which they are placed
•Reflex activity is absent, weak or ineffectual
•Heel to ear maneuvre can be performed
•Inability to maintain body temp
•Limited ability to excrete solutes in the urine
•Increased susceptibility to infection

19. Premature baby

20. Diagnostic evaluation - II
•Date of LMP
•Physical features (SGA)
–Small
–Have an emaciated look with loose skin folds of skin
(lack subcutaneous tissue). These are prominent over
the buttocks & thighs
–They look alert &often plethoric
–Head circumference exceeds the chest circumference
by > 3cm
–Often full term or borderline term in gestation

21. Cont…
•When their birth weight is plotted on the
intrauterine growth chart, it falls below the
10
th
percentile

22. Intrauterine Growth Chart

23. Problems of Very Low birth weight
Infants
Respiratory
•Respiratory distress syndrome (surfactant
deficiency) (74%)
–Resp distress within 4 hours of birth
–Antenatal corticosteroids & surfactant therapy reduce
morbidity & mortality
–Oxygen therapy, but excess may damage the retina
–Nasal CPAP/ mechanical ventilation – often required to
expand the lungs & prevent lung collapse
•Apnoeic spells/ attacks – due to immature respiratory control
mechanisms. In an apnoeic attack, the baby stops breathing,
develops slow heart rate & turns blue
•Pneumothorax
•Bradycardia & desaturations

24. Cont…
Circulation
•Hypotension – may require volume support, inotropes or
corticosteroids
•Patent ductus arteriosus – needing medical Rx or surgical
ligation
Nutrition
•NGT feeding – may be instituted
•Feeding intolerance – TPN often required
•Preterms <34 wks gestation cannot coordinate suckling &
swallowing. Therefore unable to feed from the breast
•Preterms < 30wks of gestation may not tolerate any enteral
feeds initially because of gut immaturity

25. Cont…
Gastrointestinal
•Necrotising enterocolitis (NEC) – serious,
management is medical or surgery for bowel
necrosis or perforation
Metabolic
•Hypoglycemia – common
–Immature metabolic pathways of infants predispose them
to develop hypoglycemia, metabolic acidosis &
hyperbilirubinemia
•Electrolyte disturbances
•Osteopenia of prematurity from phosphate
deficiency

26. Cont…
Temperature control
•Nurse in neutral thermal environment
•Nurse in incubator or under radiant heater
•Clothe if possible
•Humidity reduces evaporative heat loss
•Hypothermia prevention….the term babies
keep themselves by active metabolism of
brown fat stores, preterms lack brown fat

27. Cont…
Infection
•Common & potentially serious
•Immunocompromised
–Do not have sufficient humoral, cellular &
mucosal immune mechanisms to protect
themselves against bacteria
•Increased risk of early onset of infections
(Grp B stretococcus)
•Also HAI (mainly coagulase neg
staphylococcus)

28. Cont…
Eyes
•Blindness – if given excess O
2 coz of
damage to the immature retina
(retinopathy of prematurity)
Jaundice
Immature metabolic pathways of infants
predispose them to develop
hyperbilirubinemia
Anemia
•Often needs blood transfusion

29. Cont…
Brain Injury
•Hemorrhage - Immature vascular bed around
the brain ventricles. These delicate vessels may
rapture & cause Intraventricular hemorrhage
(IVH).
•Periventricular leucomalacia – ischemic white
matter injury
Organ injury
•(Brain, Eye, Lung, Intestine, Skin)

30. Management
•General principles for the care of LBW
neonates include;
–All neonates weighing ≤ 2000gms should be
admitted in the NBU
–Respiratory support
–Provide adequate warmth (temperature
regulation)
–Adequate feeding (nutrition & fluids)
–Prevent infections

31. Nursing care of the high risk
newborn & family
Assessment
•Weight, height, length & HC
•Assessment is done to determine actual &
potential needs & identify those that demand
immediate attention
•Evaluate for any obvious congenital anomalies or
evidence of neonatal distress
•Subtle changes in; feeding behavior, activity,
color, O
2 saturation or vital signs often indicate an
underlying problem

32. Cont…
Physiologic monitoring
•Monitor vital signs
•Accurate intake & output chart are kept for
the critically ill infants
•Blood works; glucose, bilirubin,
electrolytes

33. Cont…
Respiratory support
•Establish & maintain respiration in the infant, if
need be give supplemental O
2
& assist in
ventilation
•Use of NRM, CPAP mask, prongs, nasal
catheters
•Position infant in order to maximize
oxygenation & ventilation
•Explain to the parents the equipment

34. Thermoregulation
•Prevention of heat loss & maintenance of
neutral thermal environment is crucial for the
infant
•LBW infants have smaller muscle mass &
fewer deposits of brown fat for heat
production, lack of insulating subcutaneous
fat & have poor reflex control of skin
capillaries
•Placed in a heated environment

35. Cont…
•Primary methods of maintaining a neutral
thermal environment: use of incubator, a
radiant warmer, use of cotton blankets
•Incubator should be prewarmed before
placing the infant
•Infants should be clothed & warmly
wrapped in blankets when removed from
the incubator for feeding or cuddling

37. Cont…
•Complications of hyperthermia that the
nurse MUST watch out for include;
–Dehydration
–Hyponatremia
–Plethora
–Reduced urine output

38. Cont…
•A high humidity atmosphere contributes
to body temperature maintenance by
reducing evaporative heat loss
•Skin to skin (kangaroo) contract
between stable preterm infant & mother
maintains body temperature

39. Skin to skin on mother’s chest

40. 40
Kangaroo Nutrition
Exclusive breastfeeding
Initially tube or cup feeding
before breastfeeding is
established

41. Kangaroo Mother Care (KMC)
•KMC is the care of a small baby who is
continuously kept in skin-to-skin contact
with the mother.
•It provides the newborn with low birth weight
or preterm baby with the benefits of
incubator care & is cheaper.
•It is the best way to keep a small baby warm
& it also helps establish breast feeding

42. Advantages of KMC to the baby
•Keeps the baby warm
•Baby feeds more easily
•Episodes of apnea are less frequent
•Infections are prevented
•Baby grows well

43. Indications for KMC
•Any low birth weight (LBW) baby who is
stable
•Not requiring special treatment e.g. O
2 or
IVF

44. When to start KMC
•The baby must be able to breathe on his/
her own
•The baby must be free of life threatening
disease or malformations
•The ability to breast feed is not essential,
other methods of feeding can be used until
the baby can breastfeed

45. Cont…
Protection from infection
•Through, meticulous hand washing
•Personnel with infectious disorders should be
barred from the unit
•Ensure early & exclusive breast milk feeding
•Care of the umbilical stump
•Avoid unnecessary interventions e.g. IV lines
& needle pricks

46. Cont…
•Ideally one baby per incubator
•Benefits of gowning by visitors & hospital
staff, not supported by research
•Cleaning of equipment that comes into
contact with the infants e.g. feeding equip

47. Cont…
Hydration
•Administration of supplimental parenteral
fluids to supply additional calories,
electrolytes (K
+
& Na
+
) or water
•IV infusions should be delivered by
infusion pumps/ solusets
•Infants who are ELBW, on phototherapy
have increased insensible water losses

48. Cont…
•IVF may consist of;
–10% Dextrose + Na( 2-3 mEq/kg) + K (2-
3mEq/kg)
–Asepsis should be observed when preparing
these solutions
–Fluids to be administered via solusets & the
flow monitored. Too rapid infusion may led to
congestive heart failure

49. Cont…
Nutrition
•LBW & preterms are at risk of altered nutritional
status because of poor nutritional stores &
several physical & developmental xtics
•Suckling & swallowing are not coordinated until
32 to 34 wks of gestation & synchronization
occurs after 36 wks.
•Gag reflex is also not well developed hence
infants highly prone to aspiration

50. Cont…
•Gestation ≥34 wks infants can be breast,
bottle or cup fed safely unless otherwise ill
•Those less than 34 wks gestation usually
need tube feeding
•Those less than 32 wks should, as a rule
be tube fed

51. Feeding Schedule
•Neonates >1500gms
–60mls/kg/day
–Increase by 20mls/kg every day
•Neonates < 1500gms
–80mls/kg/day
–Increase by 20mls/kg every day
•Feeding done 3 hourly
•Breast feeding/EBM (NGT/ Cup feeding)
formula milk (Cow & Gate/ Pre-nan)

52. Cont…
Preterm behavior that indicates readiness
for oral feedings;
Strong vigorous suck
Coordination of suckling & swallowing
Gag reflex
Suckling on the gavage tube, hands
Rooting reflex

53. Cont…
•Parenteral nutrition indicated when;
–Severe feed intolerance
–GI abnormality including Necrotizing
enterocolitis (NEC)
•Energy conservation
–Minimal handling/ disturbance of the infant

54. Cont…
•Maintain optimal thermal environment
•Gavage feeding as appropriate
•Promote oxygenation
•Prone position is best

55. Skin care
•No alkaline soap for bathing
•Clean skin with water (top tailing)
•Decrease use of adhesive tape

56. Others…
•Family support & involvement
•Facilitate bonding
•Facilitate parent-infant relationship
•Administration of medication neonatal pain
•Neonatal loss – dealing with it

57. Cardiovascular complications
•Congenital heart defects are the most serious
cardiovascular disorders
•PDA
•Persistent hypertension of the new born (PPHN);
is characterised by severe pulmonary hypertension
& large right to left shunt thru foramen ovale &
ductus arteriosus
•Anemia- loss of blood from hemorrhage during
delivery, frequent blood specimen withdrawal &
inadequate erythropoiesis

58. Long term complications
•Cerebral palsy (45%)
•Vision impairment (35%)
•Hearing impairment (25%)
•Neurodevelopment impairment

59. Nursing diagnoses
•Fluid volume deficit rlt dehydration
•Imbalanced nutrition; less than body requirement rlt
inadequate intake
•Impaired gaseous exchange rlt lung immaturity/ deficient
surfactant
•Impaired thermoregulation related to immaturity of skin
•Impaired skin integrity rlt hyperbilirubinemia
•Risk for impaired parent-infant attachment/ bonding rlt
prolonged hospitalization
•Risk for infection rlt immature defense/ immune system
•Anxiety rlt acute hospitalization of baby/ therapies given
to the baby
•Knowledge deficit rlt first time mother/ level of education/
critical illness of the neonate

60. LARGE FOR GESTATION
AGE (LGA) BABY
Hannah Inyama

61. Definition
•This is a baby with a birth weight of more
than 4kgOR
•A baby whose birth weight is above the
90
th
percentile for the gestation

62. Intrauterine Growth Curve

63. Diagnosis
•Suspect or expect a LGA if there is;
–History of diabetes in pregnancy
–History of previous large babies

64. Associated problems
•The following complications are
associated with LGA babies;
–Hypoglycemia
–Birth asphyxia
–Birth injuries
–Jaundice
–Prone to infections

65. Management
•Initiate breast feeding immediately &
continue feeding on demand
•Recognize the associated problems &
manage e.g. Asphyxia
•Monitor blood sugar levels
•Keep baby warm
•Mother should be investigated for diabetes

66. ???

67. Necrotizing enterocolitis
•Definition:- It is acute inflammatory
disease of the bowel.
•Risk is increased in the preterm neonates
•It is caused by bacterial invasion of
ischemic bowel wall and may be
accelerated by feeding with milk.
•Its characterized by gross abdominal
distention

68. Necrotizing enterocolitis
(NEC)

69. Contributing factors….
•Intestinal ischemia
•Colonization of pathological bacteria
•Substrate e.g. formula/ cow milk in the
intestinal lumen
•Breast milk confers immunity ;-
•IGA
•macrophages, lymphocytes
•complement components
•lysozyme, lactoferrin
•acetylhydrolase

70. Contributing factors….
•Prematurity:
–90% of cases are premature infants
–immature gastrointestinal system
•mucosal barrier
•poor motility
–immature immune response
•Enteral Feedings:
–> 90% of infants with NEC have been fed
–provides a source for H2 production
–hyperosmolar formula/medications
–aggressive feedings (too much volume)

71. Pathophysiology
•The damage to mucosal cells lining the bowel
wall is great. Diminished blood supply to these
cells cause their death in large numbers. Their
function is lost (mucus production) making the
wall to be attacked by proteolytic enzymes. This
causes the bowel wall to swell & breakdown, be
permeable to macromolecules. Gas forming
bacteria invades the damaged areas causing
presence of air in the submucosal or subserosal
surfaces of the bowel (aka Pneumatosis
intestinalis or portal air). Free air may be
present if the bowel has already perforated.

72. Cont…
Inflammatory Mediators involved;-
•Inflammatory cells (macrophage) Platelet
activating factor (PAF) Tumor necrosis
factor (TNF) Leukotriene C4, Interleukin
1, 6
The Primary Infectious Agents include;-
•Bacteria, Bacterial toxin, Virus, Fungus

73. Clinical manifestations
•Distended abdomen
•Blood in stool or gastric content
•Localized abdominal wall erythema
•Bilious vomitus
•Hematochezia
•Others (non specific); lethargy, poor feeding,
hypotension, vomiting, apnea, decreased
urine output, jaundice, unstable temperature

74. Diagnosis
Radiological findings:
•The classic radiographic finding is pneumatosis
intestinalis or portal air.
•Free air may be present if the bowel has already
perforated.
•Sausage shaped dilatation of the intestine that progress
to marked distention
Laboratory findings include; anemia, leukopenia,
leukocytosis, metabolic acidosis & electrolyte imbalance
•Causative organisms are cultured in blood

75. Therapeutic management
Prevention is key!!!!! – withhold oral feedings for at
least 24 to 48 hours for infants who believed to
have suffered;-
– Birth asphyxia, ELBW & VLBW
Management: admission to a neonatal critical care
unit.
•Primarily, ABC stabilization, fluid resuscitation, and
the administration of antibiotics.
•Laboratory evaluation should include a CBC, blood
culture, and serum electrolytes.

76. Cont…
•Use of breast milk during enteral feeding
because it confers passive immunity
•Preterm infants fed with cow milk formulae
are 6x more likely to develop this condition
than if they are fed only breast milk.

77. Cont…
•Once NEC is confirmed,
•Discontinue all oral feedings & begin parenteral
feeds
•Do abdominal decompression via nasogastric
suction
•Administer IV antibiotics; Ceftriaxone 50mg/kg OD
for 5 days
•Correct volume depletion, electrolyte abnormalities
•Oxygen administration to correct acid-base
imbalances & hypoxia

78. Prognosis
•It is good with early recognition &
treatment.
•If the condition deteriorates under medical
management, surgical resection &
anastomosis are performed for bowel
perforation

79. Complications
Development of strictures
Malabsortpion if extensive bowel resection
has been necessary
Fistulas
Short-gut syndrome
Abcess

80. Nursing Care
•Assist with diagnostic procedures
•Monitor vital signs including BP for changes that
might indicate bowel perforation, septicaemia or
cardiogenic shock
•Avoid rectal temperatures because of increased
danger of perforation
•Leave the baby without diaper & position in
supine or on the side to avoid pressure on the
distended abdomen

81. Cont…
•Parenteral nutrition
•Hydration needs & monitoring input & output
•Administer antibiotics
•Introduce oral feeds from 7 – 10 days after
diagnosis & treatment depending on the
condition of the infant
•Infection control a NEC is infectious; strict hand
washing, isolation

82. The
End!!!