Module 8: Newborns at Risk
Comprehensive Study Guide
📊 Classifications by Gestational Age and Birth Weight
🚨 CRITICAL CONCEPT: The more premature the infant, the greater the risk for ALL complications!
Remember: Gestational age is the STRONGEST predictor of neonatal outcomes.
📊 Classifications by Gestational Age and Birth Weight
| Classification | Definition | Key Characteristics | Primary Concerns |
|---|---|---|---|
| Extremely Preterm | <28 weeks | • Translucent skin • Fused eyelids • No ear cartilage • Minimal subcutaneous fat |
• Survival 80-90% • High risk IVH, ROP • Chronic lung disease • Neurodevelopmental issues |
| Very Preterm | 28-32 weeks | • Thin skin • Some ear cartilage • Weak suck • Poor tone |
• RDS common • Feeding difficulties • Temperature instability • Apnea of prematurity |
| Late Preterm | 34 0/7 - 36 6/7 weeks | • Look mature • May have good tone • Inconsistent feeding • Sleepy |
• Hypoglycemia • Jaundice • Feeding problems • Readmission risk |
| Term | 37-42 weeks | • Full subcutaneous fat • Good muscle tone • Strong suck • Alert periods |
• Transition issues • Birth injuries • Congenital anomalies |
| Post-term | >42 weeks | • Peeling skin • Long nails • Meconium staining • Alert, wide-eyed |
• Meconium aspiration • Hypoglycemia • Polycythemia • Poor placental function |
Birth Weight Classifications
| Category | Weight | Percentile | Associated Risks |
|---|---|---|---|
| ELBW (Extremely Low) |
<1000g | N/A | • Mortality 10-50% • All preterm complications • Long NICU stay |
| VLBW (Very Low) |
<1500g | N/A | • IVH risk 25% • NEC risk 7% • ROP requiring treatment |
| LBW (Low) |
<2500g | N/A | • Feeding difficulties • Temperature instability • Hypoglycemia |
| SGA (Small for GA) |
Any | <10th | • Hypoglycemia • Polycythemia • Temperature instability |
| AGA (Appropriate) |
Any | 10th-90th | • Based on GA |
| LGA (Large for GA) |
Any | >90th | • Birth trauma • Hypoglycemia • Respiratory issues |
👶 Comprehensive Preterm Infant Management
PRETERM Care Priorities:
Pulmonary support
Regulate temperature
Electrolyte balance
Touch gently (skin care)
Eat (nutrition)
Reduce stimulation
Monitor for complications
Pulmonary support
Regulate temperature
Electrolyte balance
Touch gently (skin care)
Eat (nutrition)
Reduce stimulation
Monitor for complications
System-by-System Assessment and Management
🫁 Respiratory System
Assessment:- Respiratory rate (normal: 30-60)
- Work of breathing (retractions, grunting)
- Color (central cyanosis = emergency)
- O2 saturation (target: 90-95% for preterm)
- Blood gases
- Position: prone or side-lying
- CPAP for mild distress
- Surfactant within 2 hours if indicated
- Mechanical ventilation if severe
- Gentle suctioning only as needed
🌡️ Thermoregulation
Assessment:- Axillary temp q1-2h initially
- Signs of cold stress: ↓ temp, ↑ O2 needs
- Environmental temperature
- Skin color and perfusion
- Radiant warmer or incubator
- Plastic wrap for ELBW in delivery room
- Warm blankets, hat
- Kangaroo care when stable
- Gradual weaning to open crib
💧 Fluid & Electrolytes
Assessment:- Weight (expect 5-15% loss)
- Urine output (1-3 mL/kg/hr)
- Skin turgor, fontanels
- Electrolytes q8-12h initially
- Blood glucose
- IV fluids: start 60-80 mL/kg/day
- Increase by 10-20 mL/kg/day
- Humidified environment for ELBW
- Monitor for SIADH
- Careful I&O documentation
🍼 Nutrition
Assessment:- Feeding readiness cues
- Suck-swallow-breathe coordination
- Gastric residuals
- Abdominal girth
- Stool pattern
- TPN initially for VLBW
- Trophic feeds: 10-20 mL/kg/day
- Advance slowly: 20 mL/kg/day
- Fortify breast milk at 100 mL/kg/day
- Non-nutritive sucking
⚠️ Major Complications of Prematurity
⚠️ Remember: The earlier the gestation, the higher the risk AND severity of ALL complications!
1. Respiratory Distress Syndrome (RDS)
| Aspect | Details |
|---|---|
| Pathophysiology | • Surfactant deficiency → alveolar collapse • Peak incidence: 24-28 weeks (60-80%) • Decreases with advancing GA |
| Clinical Signs | • Onset within minutes to hours • Tachypnea (>60) • Grunting, nasal flaring • Retractions (subcostal, intercostal) • Cyanosis in room air |
| Diagnostics | • CXR: ground glass, air bronchograms • ABG: hypoxemia, hypercarbia • ↓ lung compliance |
| Management | • IMMEDIATE: CPAP in delivery room • Surfactant within 2 hours • Mechanical ventilation if CPAP fails • Target SpO2 90-95% • Minimal handling |
2. Bronchopulmonary Dysplasia (BPD)
Definition: O2 requirement at 36 weeks postmenstrual age OR >28 days of life
| Severity | O2 Requirement at 36 weeks PMA | Management Focus |
|---|---|---|
| Mild | Room air | • Monitor growth • RSV prophylaxis |
| Moderate | <30% O2 | • Diuretics PRN • Nutrition optimization |
| Severe | ≥30% O2 or PPV | • Steroids considered • Home O2 likely |
3. Intraventricular Hemorrhage (IVH)
| Grade | Location | Outcomes | Nursing Care |
|---|---|---|---|
| I | Germinal matrix only | Usually good | • Minimal stimulation • Midline positioning |
| II | Into ventricle, no dilation | 90% normal development | • Cluster care • Monitor HC daily |
| III | With ventricular dilation | 35% severe disability | • Elevate HOB 30° • Serial HUS |
| IV | Parenchymal involvement | 90% severe disability | • Prepare for VP shunt • Seizure precautions |
🚨 IVH Prevention Bundle:
• Delayed cord clamping • Minimal handling first 72h • Midline head position
• Avoid rapid fluid boluses • Maintain normothermia • Prevent pneumothorax
4. Necrotizing Enterocolitis (NEC)
NEC Warning Signs - "BAD GUT":
Bloody stools
Abdominal distention
Decreased bowel sounds
Gastric residuals ↑
Unstable vitals
Temperature instability
Bloody stools
Abdominal distention
Decreased bowel sounds
Gastric residuals ↑
Unstable vitals
Temperature instability
| Stage | Clinical Signs | X-ray Findings | Management |
|---|---|---|---|
| I - Suspected | • Feeding intolerance • Mild distention • Guaiac + stools |
Normal or ileus | • NPO × 3 days • Antibiotics • Serial exams |
| II - Definite | • Absent bowel sounds • Tenderness • Metabolic acidosis |
Pneumatosis intestinalis | • NPO × 7-14 days • TPN • Antibiotics × 10d |
| III - Advanced | • Shock • DIC • Peritonitis |
Pneumoperitoneum | • Surgery • Pressors • Ventilation |
🏥 Acquired Conditions in Newborns
Respiratory Conditions Quick Reference
| Condition | Typical Patient | Key Features | Management |
|---|---|---|---|
| TTN (Transient Tachypnea) |
• Term/late preterm • C-section • Male |
• Onset: birth-2h • Tachypnea only • CXR: wet lungs |
• O2 PRN • NPO if RR >60 • Resolves 24-72h |
| MAS (Meconium Aspiration) |
• Post-term • SGA • Fetal distress |
• Barrel chest • Coarse crackles • CXR: patchy infiltrates |
• NO deep suctioning • Surfactant • May need ECMO |
| PPHN (Persistent Pulm HTN) |
• Any severe lung disease • Diaphragmatic hernia • Sepsis |
• Labile O2 sats • Pre/post ductal difference • Loud S2 |
• Minimize stimulation • Sedation • iNO • ECMO if severe |
| Pneumothorax | • Ventilated infants • Meconium • CPAP |
• Sudden deterioration • ↓ breath sounds • Shift of heart sounds |
• Transillumination • Needle decompression • Chest tube |
Hyperbilirubinemia Management
⚠️ KNOW YOUR NOMOGRAM! Treatment thresholds depend on:
• Gestational age • Hours of life • Risk factors (hemolysis, G6PD, sepsis)
| Type | Onset | Causes | Treatment |
|---|---|---|---|
| Physiologic | Day 2-3 | • Normal RBC turnover • Immature liver |
• Usually none • Feed frequently |
| Pathologic | <24 hours | • ABO/Rh incompatibility • G6PD deficiency • Sepsis |
• Phototherapy • Exchange transfusion • IVIG for hemolysis |
| Breast Milk | Day 4-7 | • Factors in breast milk • ↓ intake |
• Continue breastfeeding • Photo if high |
✅ Phototherapy Nursing Care:
• Eye protection ALWAYS • Maximize skin exposure • Turn q2h
• Monitor temperature • Increase fluids 10-20% • Check bili q6-12h
Sepsis in the Newborn
| Type | Timing | Common Organisms | Risk Factors |
|---|---|---|---|
| Early-Onset | <72 hours | • GBS (#1) • E. coli • Listeria |
• Maternal GBS+ • PROM >18h • Maternal fever |
| Late-Onset | >72 hours | • CONS • S. aureus • Candida |
• Central lines • VLBW • Prolonged antibiotics |
🚨 Subtle Signs of Sepsis: "Not Acting Right"
• Temperature instability (high OR low) • Feeding intolerance • Lethargy
• Irritability • Apnea • Glucose instability • "Just doesn't look good"
Infant of Diabetic Mother (IDM)
Problems to Anticipate
- Hypoglycemia (30-50%)
- Macrosomia → birth trauma
- RDS (insulin ↓ surfactant)
- Polycythemia
- Hypocalcemia
- Hypomagnesemia
- Cardiac defects
Management Protocol
- Blood glucose at 30min, 1h, 2h, 4h
- Feed within 30 minutes
- IV glucose if BG <40 mg/dL
- Check Ca++ at 24h
- Echo if murmur
- Monitor for plethora
💊 Neonatal Abstinence Syndrome (NAS)
NAS Assessment - "WITHDRAWS":
Wakefulness (↑)
Irritability
Tremors
High-pitched cry
Diarrhea
Respiratory distress
Autonomic dysfunction
Weight loss
Seizures (severe)
Wakefulness (↑)
Irritability
Tremors
High-pitched cry
Diarrhea
Respiratory distress
Autonomic dysfunction
Weight loss
Seizures (severe)
| Drug Class | Onset of Symptoms | Duration | Key Features |
|---|---|---|---|
| Opioids | 24-72 hours | Days to weeks | • Classic NAS • Finnegan score • May need morphine |
| Cocaine | Birth-48 hours | 2-3 days | • Jittery • Poor feeding • No pharmacologic tx |
| Methamphetamine | Birth-24 hours | Days | • Agitation • Poor sleep • SGA common |
| SSRIs | Birth-48 hours | 2-4 days | • Mild symptoms • Supportive care only |
📋 Finnegan Scoring:
• Score q4h after feeding • Start within 2h of birth
• Score ≥8 × 2 consecutive = start treatment
• Score ≥12 × 1 = start treatment
🧬 Congenital Conditions
Congenital Heart Defects - Presentation by Age
| Timing | Defects | Why This Timing? | Key Signs |
|---|---|---|---|
| Day 1 | • TGA • TAPVR • Hypoplastic left heart |
Depend on mixing | • Cyanosis • Tachypnea • Poor perfusion |
| Day 2-7 | • Coarctation • Critical AS • Interrupted arch |
PDA closing | • Shock • Weak pulses • Acidosis |
| Week 2-8 | • Large VSD • Large PDA • AV canal |
↓ PVR | • CHF signs • Poor feeding • Sweating |
🚨 Prostaglandin E1 (PGE1) for Ductal-Dependent Lesions:
• Dose: 0.05-0.1 mcg/kg/min • Keep PDA open
• Side effects: Apnea (intubate before transport!), fever, flushing
Neural Tube Defects
| Type | Description | Immediate Care | Long-term Issues |
|---|---|---|---|
| Anencephaly | Absence of brain/skull | Comfort care only | Incompatible with life |
| Encephalocele | Brain tissue herniation | • Protect sac • Neurosurg consult |
Depends on location/size |
| Spina Bifida Occulta | Vertebral defect only | None urgent | Usually asymptomatic |
| Myelomeningocele | Spinal cord + meninges | • Sterile saline dressing • Prone position • Surgery <24h |
• Paralysis below • Bowel/bladder • Hydrocephalus |
GI/GU Malformations
⚠️ Tracheoesophageal Fistula (TEF) - The 3 C's:
• Choking • Coughing • Cyanosis with feeds
IMMEDIATE: NPO, elevate HOB, continuous sump suction!
| Condition | Key Features | Immediate Management |
|---|---|---|
| Diaphragmatic Hernia | • Scaphoid abdomen • Respiratory distress • Bowel sounds in chest |
• Intubate immediately • OG to decompress • NO bag-mask! |
| Omphalocele | • Covered defect • Central • Associated anomalies |
• Cover with plastic wrap • NG decompression • IV fluids |
| Gastroschisis | • No covering • Right of umbilicus • Usually isolated |
• Bowel in bag to umbilicus • Position right side • Temp support |
| Imperforate Anus | • No anal opening • May have fistula • Associated with VATER |
• NPO • NG decompression • Surgery timing varies |
🏠 Discharge Planning for High-Risk Infants
✅ Discharge Criteria for Preterm Infants:
• Maintaining temperature in open crib × 24-48h
• Taking all feeds PO with weight gain
• No apnea/bradycardia × 5-7 days
• Parents demonstrate competent care
Parent Education Priorities
Before Discharge
- CPR certification
- Car seat test (90-120 min)
- Feeding demonstration
- Medication administration
- Signs of illness
- When to call provider
- Equipment use (if needed)
Follow-up Needs
- PCP within 48-72h
- Specialty clinics PRN
- Early intervention referral
- Hearing screen passed
- ROP exam scheduled
- Synagis if eligible
- Home health if needed
💔 Supporting Families Through Perinatal Loss
Remember: How you support the family in the first hours impacts their grief journey forever.
Your calm, compassionate presence matters more than perfect words.
| DO | DON'T |
|---|---|
| • Use baby's name • Offer memory making • Allow unlimited time • Follow their lead • Provide privacy • Offer chaplain/support |
• Rush any decisions • Use clichés ("better now than later") • Avoid the topic • Make decisions for them • Judge their reactions • Forget the partner's grief |
📋 Quick Reference: Must-Know Values
| Parameter | Normal Range | Critical Values |
|---|---|---|
| Blood Glucose | 45-120 mg/dL | <40 or >150 |
| Calcium | 7-12 mg/dL | <7 (seizures) |
| Hematocrit | 45-65% | >65 (polycythemia) |
| Bilirubin (term) | Based on nomogram | >20-25 (kernicterus risk) |
| Temperature | 36.5-37.5°C | <36.5 or >38°C |
🚨 EMERGENCY Conditions - Act IMMEDIATELY:
• Pneumothorax with shift • Seizures • Shock • Severe hypoglycemia
• Complete heart block • Ductal-dependent lesion with closing PDA