HIGH RISK NEWBORN AND FAMILYPresented by:

Princess P. BarnuevoStudent, Master of Arts in Nursing

OVERVIEW

Key facts about neonatal mortality

Every year nearly 41% of all under-five child deaths are among newborn infants, i.e. the neonatal period.

75%of all newborn deaths occur in the first week of life.

In developing countries nearly half of all mothers and newborns do not receive skilled care during and immediately after birth.

Where are child deaths occurring?

Only 2 WHO regions account for more than 70% of all under-five deaths:

42% in the African region 29% in South-east Asia region

Only 6 countries account for 50% of all child deaths (2002 data):

India (Sear)Nigeria (Afr)China (Wpr)Pakistan (Emr)Ethiopia (Afr)DR Congo (Afr)

Source: Special analysis detailed in The Lancet Every Newborn Series - forthcomingThe lives of more than 3 million babies and women could be saved each year with high coverage of quality care around birth and care for small and sick babies

Care around birth gives a triple return on investments by reducing maternal and newborn deaths and stillbirths

Major Causes of Under 5 Child Mortality

Bryce et al. WHO estimates of the causes of death in children. Lancet 2005

Neonatal mortality :-

Birth process was the antecedent cause of 2/3 of deaths due to infections

Birth asphyxia in developing countries

Hypothermia and newborn deaths

Ophthalmia neonatorum is a common cause of blindness

6 Cleans for baby.

Neonatal mortality: Low birth weight

Place of childbirth◦ At least 2 out 3 childbirths in developing

countries occur at home◦ Only half are attended by skilled birth

attendants

Locally The Philippines is one of the 42 nations

that account for 90% under-five mortality rate

An estimated 82, 00 Filipino children die annually before their fifth birthday

37% of these children are newborns less than 28 days old

MDG 4: Reduce Child Mortality

Target : Reduce by two thirds, between 1990 and 2015, the child mortality rate:

- Reduce Under 5-mortality rate from 80.0 to 26.7 (per 1,000 LB)

- Reduce Infant mortality rate

from 57.0 to 19.0 (per 1,000 LB)

Solutions exist ….

Skilled care: skilled care during pregnancy, childbirth and in the post-natal period

Infant feeding: exclusive breastfeeding, complementary feeding and micronutrients

Vital vaccines: measles and tetanus immunization and other conventional and new vaccines

Combating diarrhoea: low osmolarity ORS and zinc in case management of diarrhoea, antibiotics for dysentery

Treating pneumonia and newborn sepsis: prompt treatment with appropriate antibiotics

Where appropriate: Combating malaria Preventing and caring for HIV (mother and child)

Newborn Priorities in First Days of Life

High Risk Newborn Nursing Care

The

1st 24 hours of Life

The first 24 hours of life is a very significant and a highly vulnerable time due to critical transition from

intrauterine to extrauterine life

Immediate Care of the Newborn• Airway and

Breathing

• Circulation

• Temperature

• Fluid and

Electrolyte Balance

Newborns undergo profound physiologic

changes at the moment of birth.

Within minutes after birth, a newborn has to initiate

respirations, and adapt a circulatory system to

extrauterine oxygenation. Within 24 hours, neurologic,

renal, endocrine, and gastrointestinal functions

must be operating competently for life to be

sustained.

Initiating and Maintaining Respirations

Breathing is initiated by the second stage of labor.

Most neonatal deaths within the first 24-48 hours are primarily caused by inability to initiate breathing.

Lung functions only begins after birth.

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Airway & Breathing Suction gently & quickly

using bulb syringe or suction catheter

Starts in the mouth then, the nose to prevent aspiration

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Airway & Breathing Stimulate crying by rubbing Position properly- side lying /

modified t-berg Provide oxygen when necessary

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Circulation It is initiated by lung expansion or

pulmonary ventilation and is completed by the cutting of the umbilical cord.

Gas exchange function is transferred from placenta to the lungs.

Increased metabolism to maintain body temperature and hence increased cardiac output.

Three shunts in the fetal circulation

1. Ductus arteriosus  -from pulmonary artery to aorta -protects lungs against circulatory overload -allows the right ventricle to strengthen 2. Ductus venosus  -fetal blood vessel connecting the umbilical vein to the IVC3. Foramen ovale - shunts highly oxygenated blood from right atrium to left atrium

Flow Chart of Fetal Circulation

At birth With the first breaths of life, the lungs begin to

expand. As the lungs expand, the alveoli in the lungs are cleared of fluid.

An increase in the baby's blood pressure and a significant reduction in the pulmonary pressures promotes the closure of ductus arteriosus.

These changes increase the pressure in the left atrium of the heart, which decrease the pressure in the right atrium. The shift in pressure stimulates the foramen ovale to close.

The closure of the ductus arteriosus and foramen ovale completes the transition of fetal circulation to newborn circulation.

Table 1.1 Structures at Birth and the Remnants After its Obliteration

STRUCTURE

APPROPRIATE TIME OF CLOSURE

STRUCTURE

REMAINING

FAILURE TO CLOSE

Foramen Ovale

1 year Fossa Ovales Atrial Septal Defect (ASD)

Ductus Arteriosus

1 month Ligamentum Arteriosum

Patent Ductus Arteriosus

Ductus Venosus

2 months Ligamentum Venosum

Umblical Arteries

2-3 months Lateral Umbilical

Artery (Inferior Iliac Artery)

Umbilical Vein 2-3 months Ligamentum Teres (Round Ligament of

Liver)

Fluid and Electrolyte Balance Principles of Fluid Balance: TBW = ICF + ECF

ECF = Intravascular + Interstitial

http://akramania.byethost11.com/OHCM/16%20%20Clinical%20Chemistry.htm

TOTAL BODY WATER COMPOSITION:

Adult TBW = 60% (40% ICF + 20% ECF) Full-term TBW = 75% (35% ICF + 40% ECF) Pre-term TBW = 90% (30% ICF + 60% ECF)

http://www.revivenaturally.com/dr-yoshitaka-ohno-md-phd/maintaining-intracellular-hydration-water.html

Why is FE management important? Many babies in NICU need IV fluids

If wrong fluids are given, NB kidneys are not well equipped to handle them

Serious morbidity can result from fluid and electrolyte imbalance

SENSIBLE VS. INSENSIBLE WATER LOSS

Sensible water loss (SWL): Easily measured

Insensible water loss (IWL): Not readily measured Evaporation from skin (66%) or respiratory tract (33%) IWL greater in lower GA Factors that increase: Immature skin, fever, radiant

warmers, phototherapy, skin defects/breakdown Factors that decrease: Mature skin, humidity, heat shields

FLUID RESTRICTIONS

Bronchopulmonary Dysplasia Respiratory Distress Syndrome

Patent Ductus Arteriosus Hypoxic-Ischemic

Encephalopathy

VOLUME OVERLOAD

and/or EDEMA

RESTR

ICTE

D

Management of F&E Goal: Allow initial loss of ECF over first

week (as reflected by weight loss), while maintaining normal intravascular volume and tonicity (as reflected by HR, UO, electrolytes, pH). Subsequently, maintain water and electrolyte balance, including requirements for body growth.

Individualize approach (no “cook book” is good enough!)

Common Electrolyte Problems

Sodium: Hypo (<130 mEq/L; worry if <125) Hyper (>150 mEq/L; worry if >150)

Potassium: Hypo (<3.5 mEq/L; worry if <3.0) Hyper > 6 mEq/L (non-hemolyzed)

(worry if >6.5 or if ECG changes )Calcium:

Hypo (total<7 mg/dL; ion<4) Hyper (total>11; ion>5)

Sodium Abnormalities:

Hyponatremia: Na < 130 mEq/L Causes: Usually due to excess free water but can

be increased Na losses/inadequate Na intake Signs/sx: lethargy, seizures, coma Tx: Restrict fluids and/or Na supplements

Hypernatremia: Na > 150 mEq/L Causes: Usually due to high water losses, rarely

excess intake Signs/sx: lethargy, seizures, coma Tx: Increase fluids and/or restrict Na

Potassium Abnormalities:

Hypokalemia: K < 3.5 mEq/L Causes: Diuretics, NG losses Signs/sx: EKG changes (flat T waves, prolonged QT,

U waves), arrhythmias, ileus, lethargy Tx: Slowly correct IV or orally

Hyperkalemia: K > 6 mEq/L Causes: Iatrogenic, severe acidosis, ARF, RBC

breakdown s/p transfusion, CAH Signs/sx: EKG changes (peaked T waves, wide QRS,

brady/tachycardia, SVT, V Tach, V fib), arrhythmias, death

Tx: D/C all K, Ca gluconate, sodium bicarbonate, albuterol, insulin + glucose, lasix, kayexalate, dialysis/exchange

* Most K is intracellular, thus serum levels might not accurately depict total body stores

** pH affects K levels: Acidosis drives K out of cell vs. Alkalosis pushes K into cell

Calcium Abnormalities:

Hypocalcemia: Ca < 7 mg/dL (iCa < 1) Causes: Prematurity, IUGR, IDM, HIE,

hypoparathyroidism, Vitamin D deficiency Signs/sx: Asymptomatic, jitteriness, irritability,

seizures Tx: Observation, repletion (Ca gluconate), or

supplementation

Hypercalcemia: Ca > 11mg/dL (iCa > 5) Rare in neonates Usually associated with preterm fortifiers (HMF)

* Important to follow Ca levels as well as Phos and Alk Phos levels

~every 2 weeks once on full feeds to screen for osteopenia

Temperature Regulation

Goal:Maintain correct body temperature range in order to:

maximize metabolic efficiencyreduce oxygen useprotect enzyme functionreduce calorie expenditure

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Challenges of thermoregulation in Neonatal care

Prior to delivery infants do not maintain temperature independently

Infant’s in-utero temp is generally 0.5˚C higher than mother’s temp

Rapid cooling occurs after delivery

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Neurologic adaptation: Thermoregulation

Maintenance of body temp is a major task

Skin is thin & blood vessels are close to the surface

Term Infants have 3x the surface to body mass of an adult

Preterm infants and SGA infants have 4x the surface mass to body mass of an adult

Preterm infants are especially susceptible to heat loss due to poor tone

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Healthy Vs. Sick Neonate

Healthy Newborn Brown adipose tissue Produces heat and

loses heat as needed

Sick or Low birth wt infants Increased energy

demand Decreased energy

store Vulnerable to heat

stress

Heat Loss Mechanisms Convection – the

flow of heat from the body surface to cooler surrounding air Eliminating drafts such

as windows or air con, reduces convection

Conduction – the transfer of body heat to a cooler solid object in contact with the baby Covering surfaces with

a warmed blanket or towel helps minimize conduction heat loss

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Radiation – the transfer of heat to a cooler object not in contact with the baby Cold window surface or

air con; moving as far from the cold surface, reduces heat loss

Evaporation – loss of heat through conversion of a liquid to a vapor From amniotic fluid; NB

should be dried immediately

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Nursing Considerations Keep dry and well-wrapped Keep away from cold objects or outside

walls Perform procedures in warm, padded

surface Keep room temperature warm

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Key Points to Know in Preventing Hypothermiao Infant most vulnerable

Premature and SGA infants Neonates requiring prolonged resuscitation Acutely ill Open skin defects (abdomen, spine)

Remember the basics Warm, humidified oxygen ASAP Warm objects before contact with infant Pre warmed Radiant warmer/incubator – utilize servo

control Rewarm cautiously- Be prepared to resuscitate