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PRETERM

INFANTSCarla Reinke, RN, MN, ARNP, CNM

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Delivery-Room Management

Certification by the Neonatal ResuscitationProgram (NRP) of the American HeartAssociation (AHA) and the American

Academy of Pediatrics (AAP) is essential forall nurses who work with premature infants.

Carla Reinke, RN, MN, ARNP, CNM

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Tendency to have difficulty with transition

Vulnerable to cold stress

More lung immaturity and RDS

More intracranial hemorrhage

More hypoglycemia

Potential for oxygen-related injuries

High risk of developing NEC

Risks for the Preterm Infant


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Follow resuscitation from NRPguidelines.

Avoid rough handling during

resuscitation.Reduce heat loss even if resuscitation

is not required.

Preterm infants may requireendotracheal intubation and surfactantadministration soon after birth.

Delivery-Room Management Precautions


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Delivery-Room Management Precautions

Administer medication slowly asrecommended by NRP guidelines.

Follow glucose levels carefully. Glycogen

stores may be decreased. Infant mayexperience hypoglycemia secondary toperinatal compromise.

Maintain normal oxygen range after

resuscitation.


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Major Physiologic Problemsof the Premature Infant

Respiratory Distress Syndrome (RDS),Broncho pulmonary Dysplasia (BPD), apnea ofprematurity and chronic lung disease

Patent Ductus Arteriosus (PDA) and

hypotension (Retinopathy of Prematurity) ROP visual

impairment or blindness from O2 & ventilator

Immune-system immaturity that increases the

risk of infection (Necrotizing EnterocolitisNEC)

Periventricular - Intraventricular Hemorrhage(P-IVH) 30% of infants < 32 wks


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Additional Physiologic Problemsof the Premature Infant

Skin immaturity and fragility

Thermoregulation

GI issues

Fluid and electrolyte imbalances related toimmature renal function

Acid-base disorders

Pain management

Developmental issues related to the CNS Impact of the NICU environment


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RESPIRATORYDISTRESS

SYNDROME


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Respiratory Distress Syndrome

Incidence 10% for all premature infants

Incidence 50% for 26 week to 28 weeks

Risk factors: Low gestational age

Male

Born to diabetic mothers

Born after an asphyxial insult before birth

Born after maternal-fetal hemorrhage

Multiple gestation


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RDS Incidence by Gestational Age


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Respiratory Distress Syndrome

Complex respiratory diseasecharacterized by diffusealveolar atelectasis(collapse) of the lungs,

primarily caused by adeficiency of surfactant.

This leads to higher surfacetension at the surface of

alveoli, which interfereswith normal exchange ofoxygen and carbon dioxide.


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NIH Recommendationsfor Use of Antenatal Steroids

Give to all pregnant women 24 to 34 weeksgestation who are at risk for pretermdelivery within 7 days:

2 doses of 12 mg of betamethasone IM 24 hoursapart OR

4 doses of 6 mg of dexamethasone IM 12 hoursapart

Repeat courses of corticosteroids shouldnot be given routinely in pregnant women.


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Signs and Symptoms of RDS

Difficulty in establishing normalrespiration, especially if infant has riskfactors for RDS

Expiratory grunting while the infant is not

crying, tachypnea (>60). Sternal orintercostal retractions, nasal flaring

Central cyanosis Intercostal and sternal retractions due to

increased rib cage compliance anddecreased lung compliance


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Evaluation of respiratory status using theSilverman-Andersen index


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Limit Stress on the InfantThermoregulation

Fluid balance and nutrition

Skin care

Pain assessment

Developmental care

Family care

RDS Treatment


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RDS Treatment

Focus is to prevent and minimizeatelectasis.

Minimize untoward effects of oxygen andbarotrauma or volutrauma.

Treat underlying cardiovascular infectionsand other physiologic problems.

Maintain a balanced physiologicenvironment.


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Surfactant Therapy

Surfactant coats the insideof the alveoli. It preventscollapse (atelectasis) andkeeps alveoli open at the

end of expiration.

It is given via endotrachealtube.

Prophylactic therapyappears more beneficialthan rescue therapy.


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Infants who received synthetic surfactant treatment have adecreased risk of pneumothorax, pulmonary interstitialemphysema, intraventricular hemorrhage, BPD, adecreased risk of neonatal mortality, a decreased risk of

mortality prior to hospital discharge and at 1 year of age.

Multiple doses lead to improved clinical outcomes.

Surfactant Therapy


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Adjunct Treatments for RDS

CPAP

A method of assisting lung expansion withcontinuous distending pressure

A valuable adjunct when spontaneousbreathing is adequate and pulmonarydisease is not excessive

Increases transpulmonary pressure;

improves oxygenation and ventilation Reduces tachypnea and grunting


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Continuous Positive Airway Pressure (CPAP)


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HFV (High Frequency Ventilation) Allows the use of small tidal volumes (smaller than

anatomic dead space) and high frequencies. Rates of 150 to 3,000 breaths per minute can be

used depending on the type of HFV. HFV limits large tidal volumes and wide ventilator

pressure swings associated with volutrauma/barotrauma caused by traditional mechanicalventilation.

Oscillation

Adjunct Treatments for RDS


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High Frequency Ventilation


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RDS Nursing Care

Any nurse caring for an infant with RDSmust:

Be familiar with RDS pathophysiology

Recognize symptoms of RDS Initiate interventions as indicated


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RDS Nursing Care

Maintain paO2 and oxygen saturation levels. Recognize importance of weaning oxygen

and other ventilator parameters. Recognize complications arising from RDS,

intubation and mechanical ventilation. Utilize proper endotracheal suctioning

techniques.


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Provide mouth and skin care. Maintain proper positioning. Provide adequate fluid and electrolyte

balance. Monitor blood glucose levels. Reduce environmental stressors. Provide parental support.

RDS Nursing Care


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BRONCHOPULMONARY

DYSPLASIA(BPD)


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BPD

A significant problem forpremature infants

Uncommon after 32 weeksgestation

A secondary disease thatdevelops in neonates treatedwith positive pressureventilation and oxygen forprimary lung problems such asRDS

7,500 new cases every year inthe United States

10% die by 1 year of age


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Signs and Symptoms of BPD

Hypoxemia with prolonged oxygenrequirement

Hypercapnia, tachypnea with increasedwork of breathing, retractions, nasal flaring

Exercise intolerance, fatigue with handling Tachycardia Episodic bronchospasm with wheezing In severe cases, CHF with cor pulmonale

Abnormal postures of neck and upper trunkAuscultation: crackles, decreased air

movement, ocas. expiratory wheezing


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Cascade of Events Occurring in BPD


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BPD Treatment

Therapy is preventive andsupportive.

Prenatally preventprematurity and using a

single course of antenatalsteroids. Includes early, careful

management of RDS, useof low ventilator

pressures, and carefuluse of oxygen andexogenous surfactanttreatment.


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APNEA OFPREMATURITY


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Apnea of Prematurity

50% of NICU infants Periods of cessation of respiration for longer

than 10 seconds to 15 seconds

Apneic episodes frequently accompanied bycyanosis, bradycardia, pallor or hypotonia

Exact cause unknown but thought to be dueto immature CNS


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Types of Apnea in Premature Infants

Central: Absent breathingmovements/ effort

Obstructive: Breathing movements

but no air flow

Mixed: Mixture of obstructive andcentral apnea


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Apnea Treatment

Cardiac and respiratory monitoring untilno apnea episodes for 5 to 7 days

Neutral thermal environment Careful positioning; avoid flexion and

hyperextension of the neck


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Attention to gastric tube placement andinfusion rate during tube feeding

Nasal CPAP Methyxanthines (oral to intravenous

aminophylline, theophylline and caffeine)

Apnea Treatment


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Apnea Nursing Care

Assess infants color, perfusion,respiratory rate, heart rate, position andoxygen saturation.

Document frequency and severity ofepisodes and type and amount ofstimulation required to interrupt theevent.

Ensure bag and mask set-ups with oxygenavailable at infant bedside.


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PATENTDUCTUS

ARTERIOSUS


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PDA

The most common cardiac complication inpremature infants

Incidence inversely related to gestational age Occurs in 45% of infants with a birth weight


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Left-to-Right Shunt Through PDA


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Signs and Symptoms of PDA

Signs and symptoms of congestive heartfailure, increased need for oxygen andinability to wean from ventilator

Widened pulse pressure, an active

precordium, bounding peripheral pulsesand tachycardia with or without a gallop

Echocardiogram most useful to evaluatePDA


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PDA Treatment

Treatment is controversial.

Medical management with fluid restrictionand diuretics may be the initial approach.

Indomethacin has been effective in closingPDAs (dosage depends on weight, gestationand renal function).


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PDA Nursing Care

Continually assess high-risk infants forpulse, heart rate, pulse pressure,perfusion, and auscultation for thepresence of a murmur.

Know dosage and contraindications forindomethacin.

Assess infant after indomethacin forductal closure, decreased urine output

and thrombocytopenia. Teach and reassure parents.


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RETINOPATHYOF

PREMATURITY


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ROP

A significant cause of blindness in childreninitiated by delay in retinal vascular growth

Retinopathy of prematurity is a disease thataffects the developing neural retina and itsvasculature

The more premature the infant, the morelikely the infant is to have ROP.

82% of infants weighing


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47% of infants weighing1,000 g to 1,500 g at birthdevelop ROP.

Other risk factors:

prolonged mechanicalventilation and oxygenadministration, hyperoxia,hypoxia, sepsis, acidosis,

shock

ROP


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Long-Term Consequences of ROP

Myopia(nearsightedness)

Strabismus (crossedeye)

Amblyopia (lazy eye) Astigmatism

Glaucoma

Late retinal

detachment Blindness


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AAP: Screening Premature


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AAP: Screening PrematureInfants for ROP

First exam occurs 4 to 6 weeks after birthor 31 to 33 weeks post conceptional age.

Two exams after pupillary dilation using

indirect ophthalmoscopy if: Weight at birth


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ROP Treatment

ROP progresses at different rates indifferent infants.

The goal of treatment for ROP is preventionof blindness.

Surgical therapiesLaser photocoagulationand cryotherapy


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LATEPRETERM


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Near Term/Late Term

Infants born at 34, 35, 36 and 37 weeks gestationalage are called NEAR TERM (AKA Late Preterm)Infants -4-5 weeks before due date

Near terms have a higher rate of post-discharge re-hospitalization and illness (sepsis) than full terminfants (Raju et al., 2006; Wang et al., 2004)


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Prevalence of Near Term Births

Near terms comprise the largest and a growingproportion of preterm (


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Near term characteristics

AGA Normal APGARS

Usually go home with MOM in 2-3 days

Considered to be healthy, like full term infant,

BUT


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They are more like preterm infants than


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They are more like preterm infants thanfull term infants

though often treated like full term newborns, near-term newborns are at risk for same problems thatprematures experience: respiratory distress,hyperbilirubinemia, hypoglycemia, feeding

problems, and neurodevelopmental delays(AWHONN).


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Risks of the Late Preterm Infant

1. Increased Mortality2. Increased Morbidity3. Respiratory Instabilityapnea4. Cardiovascular

instability5. Thermoregulation

6. Hypoglycemia7. Sepsis8. Hyperbilirubinemia9. Feeding Problems10. Neurodevelopmental

delay


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Parent Teaching

Special emphasis on warning signs to watch for

Follow up visit in 2 days.

Getting support for breastfeeding. Routine

lactation consultation.


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Hyperbilirubinemia

Hyperbilirubinemia in the Late Preterm infant hashad more cases of Kernicterus than Preterm infants.

Due to immaturity of liver and intestine,

production, elimination, and more common inBreastfed infants

Being at home predisposes them to poor feeding,poor fluid intake, poor voiding and bms which

decrease excretion of bilirubin. bilirubin usually occurs in 1st week, so the earlier

the discharge the more likely readmission


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F ll h bl h KC


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For all these problems, theres KC


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Kangaroo care

Kangaroo care is a technique practiced onnewborn, usually preterm, infants wherein the infantis held, skin-to-skin, with an adult.


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Kangaroo Care improves outcomes for preterm


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Kangaroo Care improves outcomes for pretermand near term infants

Reduces LOS in preterm

Decreases apnea

Improves sleep quality Keeps baby warm

Improves blood glucose

Decreases crying by producing calm

Improves parental bonding attachment andassumption of parental role.


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POST TERM


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Post Term Infants

Born after 42 weeks Increase risk of meconium aspiration

Hypoglycemia

Loss of subcutaneous fat

Skin peeling, vernix sparse, lanugo absent,fingernails long

Focus on prevention due date

Attention to thermoregulation & feeding


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LGA -MACROSOMIC


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Large for Gestational Age

Infants weight is in the 90th % for neonates samegestational age, may be pre, post, or full term infants

LGA does not mean post term

Most common cause maternal diabetes Infant at risk: birth injuries, hypoglycemia, and

polycythemia - macrosomia


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SMALL FORGESTATIONAL

AGE


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S ll f G t ti l A


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Small for Gestational Age

Infant whose wt is at or below the 10th % Results from failure to thrive

Is a high risk condition

SGA does not mean premature. Causes: anything restricting uteroplacental blood

flow, smoking, DM, PIH, infections

Complications: hypoglycemia, meconium aspiration,

hypothermia, polycythemia


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INFANTS OFDIABETIC

MOTHERSCarla Reinke, RN, MN, ARNP, CNM

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Infant of a Diabetic Mother


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Infant of a Diabetic Mother

Macrosomia face round, red, body obese, poormuscle tone, irritable, tremors

High risk for trauma during birth, congenitalanomalies, RDS, hypocalcemia

Hypoglycemia occurs 15-50% of time


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HYPO-

GLYCEMIACarla Reinke, RN, MN, ARNP, CNM

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Carla Reinke, RN, MN, ARNP, CNM 71

Neonatal Hypoglycemia


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Clinically significant NH is the result of an imbalancebetween glucose supply and other fuels such asketone bodies, which are released from fat. Bloodglucose concentrations often dip to 30 mg/dL within

1 to 2 hours after birth in healthy neonates, but theytypically return to more than 45 mg/dL with normalfeeding within 12 hours.

PEDIATRICS Vol. 127 No. 3 March 2011, pp. 575-579 (doi:10.1542/peds.2010-3851


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Highest Risk: SGA, LGA, infant of diabetic mothers,late-preterm.

Clinical Manifestations: as jitteriness, cyanosis,seizures, an apneic episode, tachypnea, weak or high-pitched cry, floppiness, or lethargy, poor feeding, oreye-rolling

If symptomatic and blood glucose < 40 mg/dL treatwith IV glucose immediately.



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For asymptomatic at-risk infants, the initial feedshould be within 1 hour of birth, with glucosescreening 30 minutes after the first feed.

Because there is no point-of-care screening methodreliable enough to be used as the sole method forscreening for NH, the blood or plasma glucoseconcentration must be confirmed by laboratorytesting ordered stat.



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If the initial screen is lower than 25 mg/dL, theguidelines call for feeding and checking again in 1hour. If the level remains lower than 25 mg/dL,intravenous glucose is called for. If it is 26 to 40

mg/dL, the guidelines call for re-feeding and/orintravenous glucose as needed. The target glucoselevel is 45 mg/dL or higher before routine feeds.

The recommended glucose dose is a minibolus 200

mg/kg (dextrose 10% at 2 mL/kg) and/orintravenous infusion at 5 to 8 mg/kg per minute (80- 100 mL/kg/day).



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During the 4 to 24 hours after birth, feeds should becontinued every 2 to 3 hours, with glucose screeningtaking place before each feed. If a screen shows lessthan 35 mg/dL, the guideline is to feed and check

again in 1 hour.

If the glucose levels remain lower than 35 mg/dL, theguideline calls for intravenous glucose. If the level is35 to 45 mg/dL, the guideline calls for re-feeding

with intravenous glucose as needed to reach thetarget.



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SGA and Late Preterm - The screening schedulevaries slightly.

should be fed every 2 to 3 hours and screened beforeeach feeding for at least the first 24 hours after birth.

Infants of diabetic mothers and LGA with 34 weeks'gestation or more should be screened for the first 12hours after birth.



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At-risk infants should maintain normal plasmaglucose on a routine diet for at least 3 feedfastperiods before discharge.

Plasma glucose levels tend to be lower in breastfedinfants, whereas ketone body concentrations tend to

be higher than in formula-fed infants. They suggestthat breastfed infants might tolerate lower plasmaglucose because of the increased ketoneconcentrations.



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the guidelines stress that managing neonatalhypoglycemia should "not unnecessarily disrupt themother-infant relationship and breastfeeding."



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MECONIUM

ASPIRATIONCarla Reinke, RN, MN, ARNP, CNM

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Meconium Aspiration Syndrome


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Meconium Aspiration Syndrome

Occurs most often post term infants, decreasedamniotic fluid /cord compression, intrauterinegasping in response to hypoxia

Meconium enters lung obstruction & pneumonia

S & S vary from mild to severe respiratory distress:tachypnea, cyanosis, retractions, nasal flaring,grunting

Tx suction at birth, may need warmed, humidifiedoxygen, or ventilators or if Severe ECMO


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HYPOCALCEMIA

HYPOMAGNESEMIA


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Hypocalcemia occurs in 50% infants ofIDMs, also related to hypoxia andprematurity, perinatal asphyxia.

Sx: tremors

Hypomagnesemia is associated with

maternal IDM.


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HYPER

BILIRUBINEMIASEE OTHER PPT


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NECROTIZINGENTEROCOLITIS


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NEC


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NEC

The most common neonatal intestinalemergency

Characterized by intestinal ischemia, mostoften involving the terminal ileum

Pathogenesis is uncertain.

Three major factors: bowel wall ischemia;bacterial invasion of the bowel wall; enteral

feedings


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Pathogenesis of NEC


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Pathogenesis of NEC


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Three Stages of NEC


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Three Stages of NEC

1. Generalized symptoms of early sepsis, includingtemperature instability, lethargy, apnea andbradycardia, feeding intolerance, abdominaldistention, and stools that test positive for

occult blood2. Severe abdominal distention and tenderness,

visible bowel loops, grossly bloody stools,metabolic acidosis, poor perfusion and amottled skin color

3. Fulminant signs of SIRS, including shock,mixed acidosis, DIC and neutropenia


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NEC Treatment


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NEC Treatment

Goals: Stabilize the neonate. Treat the infection. Rest the intestinal tract.

Discontinue feedings. Initiate IV access for fluids and antibiotics.

NG tube to decompress GI tract


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NEC Nursing Care


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NEC Nursing Care

Monitor vital signs. Monitor blood gases and pH.

NPO

Examine for abdominal distention,tenderness, emesis, bloody stools,temperature instability, metabolic acidosis,apnea, bradycardia.

Support parents. Encourage mother to pump breasts and

freeze breastmilk.


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NOSOCOMIALINFECTIONS


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Prevention of Nosocomial Infections in


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Prevention of Nosocomial Infections inNICUs

Increased compliance withhand-hygiene standards

Improved accuracy of the diagnosis of

bacteremia Reduced line and line connection (hub)

bacterial contamination


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Prevention of Nosocomial Infections in NICUs,Continued


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Maximal barrier precautions forcentral line placement

DecreasedNumber of skin puncturesDuration of IV lipid infusionDuration of central venous line use

Continued


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INTRAVENTRICULARHEMORRHAGE (IVH)


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Intracranial Hemorrhage


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Causes:1. Sudden compression and decompression of the

head as in breech and precipitate labor.

2. Marked compression by forceps or incephalopelvic disproportion.

3. Fracture skull.


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Predisposing Factors:1. Prematurity due to physiological

hypoprothrombinaemia, fragileblood vessels and liability to trauma.

2. Asphyxia due to anoxia of the

vascular wall .3. Blood diseases.


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t ac a a e o age

Predisposing Factors:1. Subdural : results from damage to the superficial veins where

the vein of Galen and inferior sagittal sinus combine to form thestraight sinus.

2. Subarachnoid: The vein of Galen is damaged due to tear inthe dura at the junction of the falx cerebri and tentorium cerebelli.

3. Intraventricular :into the brain ventricles.

4. Intracerebral : into the brain tissues . In (1) and (2) it is usually due to birth trauma,

in (3) and (4) the fetus is usually a premature exposed to hypoxia.


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IVH/PVH


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/

50% will die. Occurs in 25% to 30% of all VLBW infants

discharged from Level III NICUs

Associated primarily with prematurity

Infants


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/

Small (Grades I and II) Grade I hemorrhage is an isolated germinal

matrix hemorrhage.

Grade Il is an IVH with normal ventricular size.

Moderate (Grade III) is an IVH with acuteventricular dilation.

Severe (Grade IV) is an IVH withparenchymal hemorrhage.


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Signs and Symptoms of IVH/PVH


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g y p /

Can be subtle; sometimes only decreasedhematocrit or hemoglobin levels

May evolve over several hours and includedecreased activity, hypotonia, altered

consciousness, respiratory disturbances Can develop rapidly, with seizures,

decerebrate posturing, fixed pupils


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Signs and Symptoms of IVH/PVH


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g y p /

1- Altered consciousness.2- Flaccidity.

3- Breathing is absent, irregular and periodic or gasping.

4- Eyes: no movement, pupils may be fixed and dilated.

5- Opisthotonus, rigidity, twitches and convulsions.

6- Vomiting .

7- High pitched cry.

8- Anterior fontanelle is tense and bulging.9- Lumbar puncture reveals bloody C.S.F.


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IVH/PVH Nursing Care


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/ g

Optimal treatment is prevention. Minimize brain tissue destruction.

Minimize pain and stress.

Minimize crying, suctioning, rapid bolusinfusions.


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IVH/PVH Nursing Care


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Maintain neutral thermal environment. Elevate head 30.

Use sucrose pacifiers, topical anesthetics forprocedures.

Provide parental support.

/ g


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Prevention of IVH and PVH


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Administer antenatal steroids. Optimize peripartum management.

Administer antenatal antibiotics forpreterm rupture of the membranes.

Delivery-room resuscitation byneonatologists and an experienced team


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Maintain the babys temperature >36centigrade.

Maintain cardiorespiratory stability whileadministering surfactant.

Optimize direct clinical management byneonatologists.

Implement measures to minimize pain andstress responses.


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Use developmentalcare.

Judiciously usenarcotic sedation (low

dose, continuous).Avoid early lumbar

puncture ( 72 hoursold).

Use optimalpositioning.


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In terms of fluid volume treatment ofhypotension, there is no evidencedemonstrating benefit of using MAP 30rather than MAP > estimated gestational

age weeks. Use postnatal indomethacin judiciously.

Optimize respiratory management.

Use postnatal dexamethasone judiciously.


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GAVAGEFEEDING


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Gavage Feeding


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g g

Used with preterm infants who have poor suck,swallow, and feeding.

Either naso or orogastric

Early feeding in 24-72 hrs not assoc with NEC,benefits fewer days on TPN, less jaundice, increasedweight gain, lower risk of osteopenia,


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Measure from tip of nose to ear lobe then to xiphoidprocess.


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Placement of Gavage Feeding tube


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Measure from tip of nose tolobe of the ear to themidpoint between thexiphoid and umbilicus.Mark the tube with tape.

Lubricate tip with sterilewater and gently insertthrough nose or mouth until placed to mark.

Placement in the tracheawill cause gag, cough orcyanosis.

Placement of Gavage Feeding tube


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Check placement: Aspirate stomach contents

Inject air and listen withstethoscope

Xray Tape tube in place Monitor babys skin integrity

at tape site and pressure

points Assess tube placement

before every feeding.

Gavage Feeding


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Attach the syringe to tube Clamp or Pinch tube and add ordered amount of

formula or breastmilk

Release clamp and allow gravity to cause flow about

1 ml/min At end of feeding clamp tube

Position to prevent aspiration right side or tummy

Document size of tube, amount & quality of residual,

type and quantity of fluid instilled and infantsresponse.

Gavage Feeding


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Method of feeding breast milk or formula through anoro or nasogastric tube.

Document: residual gastric contents (by aspirationbefore each feeding) if of previous intake can be

refed.

Document type of fluid, hourly intake

Feeding maybe stopped if residual >2/4 ml/kg or a 1

hr volume and is not resumed until assessed forfeeding intolerance.


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Auscultation for placement of gavage tube.


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PARENTALATTACHMENT


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Promote Parental Attachment


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Opening the intensive care nursery toparents

Familiarizing parents with equipment andcare.

Transporting the mother to be near herinfant

Maternal day care for premature infants

Rooming in for parents

Individualized nursing care plans

Early discharge


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Listening to parents during the infantshospitalization and after discharge

Parent support groups

Programmed contact and reciprocal

interaction Transporting the healthy premature infant to

the mother


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Home-based interventionsfor young parents

Discussion with parentsafter discharge

Kangaroo care Nurse home visitation

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Hypoxic Ie