NURSING CARE FOR A FAMILY 5.

Establishment of waste elimination

WITH A HIGH-RISK NEWBORN 6. Prevention of infection

7. Establishment of an infant–parent relationship

Assessment
8. Developmental care, or care that balances
 All infants need to be assessed at birth for
physiologic needs and stimulation for best
obvious congenital anomalies and gestational
development
age.

Nursing Diagnosis

 Ineffective airway clearance related to

presence of mucus or amniotic fluid in airway
 Ineffective cardiovascular tissue perfusion
related to breathing difficulty
 Risk for deficient fluid volume related to
insensible water loss
 Ineffective thermoregulation related to
newborn status and stress from birth weight
Initiating and Maintaining Respirations
variation
 Risk for imbalanced nutrition, less than body  Most deaths occurring during the first 48 hours

requirements related to lack of energy for after birth result from the newborn’s inability to

sucking establish or maintain adequate respirations.

 Risk for infection related to lowered immune  If respiratory activity does not begin
response in newborn immediately, respiratory acidosis will increase.

Outcome Evaluation

 Infant maintains a patent airway.

 Infant tolerates all procedures without
accompanying apnea.

NEWBORN PRIORITIES IN THE FIRST

DAYS OF LIFE

All newborns have eight priority needs in the first

few days of life:

1. Initiation and maintenance of respirations

Resuscitation
2. Establishment of extrauterine circulation
 If breathing is ineffective, circulatory shunts,
3. Control of body temperature
particularly the ductus arteriosus, can fail to
4. Intake of adequate nourishment
close.
 left-side heart pressure is stronger than right-
side pressure
 blood circulates through a patent ductus
arteriosus left to right or from the aorta to the
pulmonary artery, creating ineffective pump
action in the heart
 Struggling to breathe and circulate blood, an
infant uses available serum glucose quickly and
may become hypoglycemic.
 Resuscitation follows an organized process:
1. establish and maintain an airway,
2. expand the lungs, and
3. initiate and maintain effective ventilation.
Airway
 bulb syringe suction - removes mucus and
prevents aspiration of any mucus and amniotic
fluid present in the mouth or nose; all that is
necessary to help establish a clear airway FOR
A WELL TERM NB
 If a newborn does not draw in a first breath
spontaneously
 suction the infant’s mouth and nose with a
bulb syringe again and
 rub the back to see if skin stimulation initiates
respirations.
 Be certain an infant is dry : If a newborn has
to attempt to raise body temperature because
of chilling, this will increase the need for
oxygen, which the baby cannot supply
because breathing has not yet been initiated.
 If a newborn’s amniotic fluid was meconium
stained:
 do not stimulate an infant to breathe by
rubbing the back or administering air or
oxygen under pressure as doing so could push
meconium down into an infant’s airway
 An infant who still makes no effort at
spontaneous respirations requires immediate
laryngoscopy to open the airway.
 Laryngoscopes - Size 0 or 1 is used with
newborns.
 Infants under 1000 g need a 2.5-mm
endotracheal tube;
 those over 3000 g need a 4.0mm tube.
 Primary Apnea - In the first few seconds of life,
a newborn this severely depressed may take
several weak gasps of air and then almost
immediately stop breathing.
 Secondary Apnea - After 1 or 2 minutes of
apnea, an infant again tries to initiate
respirations with a few strong gasps.
o However, a newborn cannot maintain this
effort longer than 4 or 5 minutes.
o After this, the respiratory effort will
become weaker again and the heart rate
will fall further until the newborn stops the
gasping effort altogether.
Lung Expansion
 The sound of the baby crying is proof that lung
expansion is good.
 An infant cannot sustain effective respirations
may need oxygen by bag and mask to aid lung
expansion.
 The pressure needed to open lung alveoli for
the first time is approximately 40 cm H2O.
After that, pressures of 15 to 20 cm H2O are
generally adequate to continue inflating alveoli.
Drug Therapy
 If RespiDep is caused by narcotic during labor -
narcotic antagonist such as naloxone (Narcan)
injected into an umbilical vessel or
intramuscularly into a thigh will relieve the
depression.
 The dose of naloxone is determined by
institutional policy but is usually 0.01 to 0.1
mg/kg

Ventilation Maintenance

 If Respiratory rate is increased, undress the

baby’s chest and look for retractions.
 NB with increased RR should be placed under an
infant warmer and have the weight of clothing
removed from the chest.

Establishing Extrauterine Circulation

 Closed-Chest Massage - Perform If an infant has

no audible heartbeat, or if the cardiac rate is
below 80 beats per minute
 Depress the sternum approximately one third of
its depth (1 or 2 cm) at a rate of 100 times per
minute.
 Lung ventilation at a rate of 30 times per
minute.
 If not effective - 0.1 to 0.3 mL/kg epinephrine
(1:10,000) may be sprayed into the endotracheal
tube to stimulate cardiac function.

Maintaining Fluid and Electrolyte

Balance

 Hypoglycemia - may result from the effort the

newborn expended to begin breathing.
 Dehydration- may result from increased
insensible water loss from rapid respirations.
 Hypoglycemia are treated initially with 10%
dextrose in water to restore their blood glucose
level. LR and D5W
 Fluids are monitored carefully - a high fluid
intake can lead to patent ductus arteriosus or
heart failure.
 An output less than 2 mL/kg/hr or a specific  maintain an infant’s axillary temperature at
gravity greater than 1.015 to 1.020 suggests 97.8° F (36.5° C).
inadequate fluid intake.
 If an infant has hypotension without
hypovolemia, a vasopressor such as dopamine Radiant Heat Sources
may be given to increase blood pressure and  open beds that have an overhead radiant heat
improve cell perfusion. source.
 Hypovolemia:  Abdominal skin temperature, when measured
o tachypnea this way, should be 95.9° to 97.7° F (35.5° to
o pallor 36.5° C). If an infant’s temperature falls below
o tachycardia this level, an alarm will sound.
o decreased arterial blood pressure
 tape the probe or disk onto the infant’s
o decreased central venous pressure
abdomen between the umbilicus and the
 Normal saline or Ringer’s lactate may be xiphoid process.
administered to increase blood volume.
 DO NOT TAPE IT UNDER AN INFANT – IT WILL

Regulating Temperature CAUSE FALSE HIGH READING

 Also DO NOT PLACE IT OVER THE LIVER,
 neither too hot nor too cold because increased metabolism may lead to
 If the environment is too hot, they must falsely high readings.
decrease metabolism to cool their body.  A plastic bridge or shield placed over the child
 If it is too cold, they must increase metabolism will better preserve heat by reducing
to warm body cells convection and radiation losses; plastic wrap
o The increased metabolism required calls placed over an infant will produce this same
for increased oxygen; without this effect.
oxygen available, body cells become
Incubators
hypoxic.
 To save oxygen for essential body functions,  Use of an additional acrylic shield inside the
vasoconstriction of blood vessels occurs. incubator helps prevent radiation and
 In short, because of becoming chilled, heart convection heat loss when portholes are opened
action, breathing, and electrolytic balance are for care.
all affected.
Skin-to-Skin Care
 To prevent a newborn from becoming chilled:
o after birth, wipe an infant dry,  kangaroo care
o cover the head with a cap, and  Undress the infant except for a diaper and
o place the baby immediately under a perhaps a cap.
prewarmed radiant warmer or in a  Assist the parent to sit comfortably in a chair
warmed incubator and hold the infant snugly against his or her
o Skin-skin contact chest, skin to skin. Place a blanket over the
infant for added warmth.
Establishing Adequate Nutritional
Intake
Infants who experienced severe asphyxia at birth
usually receive intravenous fluids so they do not
become exhausted from sucking or
NECROTIZING ENTEROCOLITIS (NEC) has been ruled
out, result from the temporary reduction in oxygen
to the bowel.
 Preterm infants should be breastfed if possible
because of the immune protection this offers.
 If breastfeeding is not possible because the
infant is too immature to suck effectively, a
mother can manually express breast milk.
 Her expressed breast milk can be used in the
infant’s gavage feeding.
 BREASTMILK should be stored in nonshiny
plastic bags or bottles to avoid the infant being
exposed to polycarbonate.
 If Gavage fed, need ORAL STIMULATION –
PACIFIER.
 Except those too immature to have a sucking
reflex and infants who must not swallow air,
such as those with a tracheoesophageal fistula
Establishing Waste Elimination
 Carefully document any voidings that occur
during resuscitation. This is proof
hypotension is improving and the kidneys are
being perfused.
 Immature infants also may pass stool later than
the term infant because meconium has not yet
reached the end of the intestine at birth.
Preventing Infection
 Stresses the immature immune system
 If infection causes chilling, can lead to
increased oxygen demands
 Common viruses that affect infants in utero
are cytomegalovirus and toxoplasmosis
virus.
 Early-onset sepsis is most commonly caused
by group B streptococcus, E. coli, Kelbsiella,
until and Listeria monocytogenes.
Establishing Parent–Infant Bonding
 parents of a high-risk newborn are kept
informed of what is happening during
resuscitation at birth.
 They should be able to visit the special
nursing unit to which the child is admitted as
often as they choose, and, after washing and
gowning, hold and touch their child.
 If an infant dies despite newborn
resuscitation attempts, parents need to see
the infant without being covered by a
myriad of equipment.
o reassure themselves their newborn was
a perfect baby in every other way except
lung function or whatever was the
infant’s fatal disorder.
Anticipating Developmental Needs
Follow-up of High-Risk Infants at Home
 Thorough education and referral to a home
that care agency may be necessary to help
parents continue with the level of care that
is required when their infant is discharged
home.
 “car seat challenge” - all preterm infants be
assessed for cardiorespiratory stability in
their car seat prior to discharge
High-Risk Infants and Child Abuse
 Preterm children are at high risk for abuse
 THE NEWBORN AT RISK BECAUSE OF  INTRAUTERINE INFECTION such as rubella
ALTERED GESTATIONAL AGE OR BIRTH or toxoplasmosis or has a chromosomal

WEIGHT abnormality.

Birth weight is normally plotted on a growth Assessment

chart such as the Colorado (Lubchenco)
 A sonogram can then demonstrate the
Intrauterine Growth Chart
decreased size.
 TERM - Infants born after the beginning of  A biophysical profile including a nonstress test,
week 38 and before week 42 of pregnancy placental grading, amniotic fluid amount, and
 PRETERM - less than the full 37th week of ultrasound examination can provide additional
pregnancy information on placental function.
 POSTTERM, DYSMATURE, OR POSTMATURE
Appearance
- after the onset of week 43 of pregnancy
 overall wasted appearance
 APPROPRIATE FOR GESTATIONAL AGE
 small liver, which can cause difficulty regulating
(AGA) - Infants who fall between the 10th
glucose, protein, and bilirubin levels after birth.
and 90th percentiles of weight for their age
 poor skin turgor
regardless of gestational age
 large head because the rest of the body is so
 SMALL FOR GESTATIONAL AGE (SGA) - fall
small
below the 10th percentile
 LARGE FOR GESTATIONAL AGE (LGA) - Laboratory Findings
above the 90th percentile
 high hematocrit level
 LBW – below 2,500 g
 polycythemia - increase in red blood cells occurs
 VLBW - 1000 to 1500 g
because anoxia during intrauterine life
 EXTREMELY VERY-LOW-BIRTH-WEIGHT
stimulates the development of red blood cells.
INFANTS (EVLB) - 500 to 1000 g
- increased blood viscosity

The Small-for-Gestational-Age Infant  polycythemia is extreme, vessels may actually

become blocked and thrombus formation can
 they have experienced intrauterine growth
result
restriction (IUGR)
 hypoglycemia - decreased blood glucose, or a

Etiology level below 45 mg/dL

 MOST COMMON CAUSE of IUGR is a The Large-for-Gestational-Age Infant

placental anomaly:
-Macrosomia
o the placenta did not obtain sufficient
nutrients from the uterine arteries Etiology
o it was inefficient at transporting
 Infants who are LGA have been subjected to an
nutrients to the fetus
overproduction of growth hormone in utero.
 lack of adequate nutrition
 infants of women with diabetes mellitus
 Pregnant adolescents
 women who are obese  Delivering even though it was just Braxton-Hicks
 Extreme macrosomia occurs in fetuses of  On gross inspection, a preterm infant appears
diabetic women whose symptoms are poorly small and underdeveloped
controlled, because these fetuses are exposed
to high glucose levels.
 Multiparous women are also prone to have
large babies because with each succeeding
pregnancy, babies tend to grow larger.
 Beckwith syndrome (a rare condition
characterized by overgrowth), and congenital
anomalies such as omphalocele.

Assessment

 may have extensive bruising or

 a birth injury such as a broken clavicle or
Erb-Duchenne Paralysis
 caput succedaneum, cephalhematoma, or
 The head is disproportionately large (3 cm
molding.
greater than chest size).
Cardiovascular Dysfunction
 Scant Lanugo
 signs of hyperbilirubinemia - which may result  Skin is Ruddy
from absorption of blood from bruising and  Eyes appear small, pinna falls forward (no
polycythemia cartilage)

Hypoglycemia

 Rebound Hypoglycemia - increased insulin levels

in the uterus

A Preterm Infant

 Late Preterm – 34-37 weeks

 Early Preterm – 24-34 weeks
 Lung Surfactant forms 34th week- makes them
susceptible to RDS

Etiology

Assessment

 A good answer to her direct inquiries about

causes is, “No one really knows what causes
prematurity.” To prevent guilt of the mother.
Potential Complications
Anemia of Prematurity
 normochromic, normocytic anemia (normal
cells, just few in number)
 infant will appear pale and may be lethargic
and anorectic.
 immaturity of the hematopoietic system +
destruction of red blood cells because of low
levels of vitamin E
 Excessive blood drawing for electrolyte or
blood gas analysis
Kernicterus
 destruction of brain cells by invasion of
indirect bilirubin
 results from the high concentrations of
indirect bilirubin in the blood from excessive
breakdown of red blood cells.
 Preterm infants are more prone because
with the acidosis that occurs from poor
respiratory exchange, brain cells are more
susceptible to the effect of indirect bilirubin
than usually.
 Preterm infants also have less serum
albumin available to bind indirect bilirubin
and inactivate its effect.
 12 mg per 100 mL of indirect bilirubin
Persistent Patent Ductus Arteriosus
Pathophysiology
1. Lack of lung Surfactant
2. Difficulty in movement of blood into the
pulmonary artery
3. Pulmonary Hypertension
4. Interferes with the closure of Ductus
Arteriosus
 Adminster IV Cautiously - to avoid
increasing blood pressure and further
compounding this problem
 Indomethacin or ibuprofen may be used
 A side effect of indomethacin is oliguria, so
urine output needs to be monitored closely
if this is used, decreased platelet count,
gastric irritation.
Periventricular/Intraventricular
Hemorrhage
 periventricular hemorrhage -bleeding into
the tissue surrounding the ventricles)
 intraventricular hemorrhage -bleeding into
the ventricles
 Cause: Fragile capillaries and immature
vascular development
 Grade 1 – Bleeding in the periventricular
germinal matrix, occurring in one ventricle
 Grade 2 – bleeding within the lateral
ventricle without dilation of the ventricle
 Grade 3 – bleeding causing enlargement of
the ventricles
 Grade 4 – bleeding in the ventricles and
intraparenchymal hemorrhage
 Hydrocephalus may occur from bleeding
into the aqueduct of Sylvius
Other Potential Complications
 respiratory distress syndrome
 apnea,
 retinopathy of prematurity
 necrotizing enterocolitis
Impaired gas exchange related to
immature pulmonary functioning
 Immature pulmonary capillaries
 Lung surfactant does not form in adequate
amounts until about the 34th to 35th week of
pregnancy. Inadequate lung surfactant leads to
alveolar collapse with each expiration.
 Forces the infant to use maximum strength to
inflate lung alveoli each time.
 a preterm infant may still be in a breech position
at birth. Breech-born infants are apt to expel
meconium into the amniotic fluid.
 If the fetus aspirates either vaginal secretions or
meconium, the respiratory problem can be
aggravated by inflammation or pneumonia.
 Cesarean birth may lead to additional
respiratory complications because of retained
lung fluid.
 Give mother O2 by mask to to help infant have
adequate O2 sat, minimize analgesia
 Susceptible to Reversible Acidosis – prepare
medications, keep them warm, carry out
procedures gently because bruising can cause
hyperbilirubinemia
 Manifests Periodic Respirations (quick
successive breaths then cessation for 5-10
seconds)
 Be alarmed for true apnea (cessation for >20
seconds)
 Soft ribs causes lung collapse during respirations
and no back up muscles to be used when
fatigued
 Increased O2 causes: Pulmonary Edema and
ROP
Risk for deficient fluid volume related
to insensible water loss at birth and
small stomach capacity
 A preterm newborn experiences a high
insensible water loss because of a large body
surface relative to total body weight.
 also cannot concentrate urine well because of
immature kidney function.
 Intravenous fluid administration typically begins
within hours after birth to fulfill this fluid
requirement and provide glucose to prevent
hypoglycemia.
 Intravenous fluid should be given via a
continuous infusion pump to ensure a constant
infusion rate and prevent accidental overload.
 Always assess iv site - because if infiltration
should occur, the lack of subcutaneous tissue
places a preterm newborn at risk for damaged
tissue.
 Specially designed 27-gauge needles are
available for use on small veins.
 If lack adequately sized peripheral veins for even
this small a needle - need to receive intravenous
fluid by an umbilical venous catheter.
 Monitor the baby’s weight, urine output and
specific gravity, and serum electrolytes to
ensure adequate fluid intake.
 Too little fluid and calories can lead to
dehydration and starvation, acidosis, and
weight loss
 Overhydration may lead to nonnutritional
weight gain, pulmonary edema, and heart
failure
 Measure urine output by weighing diapers
rather than using urine collection bags, as
disposable collection bags can lead to skin
irritation
 40 to 100 mL per kg per 24 hours, compared
with the normal 10 to 20 mL per kg per 24 hours.
The specific gravity is low, rarely more than
1.012 (normal 1.030).Because they cannot
concentrate urine.
 test urine for glucose and ketones.
 Hyperglycemia caused by the glucose infusion
may lead to glucose spillage into the urine and
an accompanying diuresis, and fluid loss.
 If too little glucose is being supplied and body
cells are using protein for metabolism, ketone
bodies will appear in urine.
 Blood glucose should range between 40 and 60
mg/dL
 Check for blood in stools to evaluate possible
bleeding from the intestinal tract. This is helpful
in determining the possible cause
hypovolemia
Risk for imbalanced nutrition, less
than body requirements, related to
additional nutrients needed
maintenance of rapid growth, possible
sucking difficulty, and small stomach
 a preterm newborn requires a larger amount of
nutrients than the mature infant.
 hypocalcemia (decreased serum calcium) or
 azotemia (low protein level in blood).
 Delayed feeding and a resultant decrease in
intestinal motility may also add
hyperbilirubinemia
 Immature Stomach and intestine – Milk
Digestion Problems
 Immature Reflexes – ineffective sucking and
swallowing
 Immature Cardiac Sphincter – allows more
incedents of cardiac regurgitation
Feeding Schedule
 Delayed if with TPN or IVF
 Feeding is begun as soon as an infant is able to
tolerate them to prevent deterioration of the
intestinal villi.
 A preterm infant needs 115 to 140 calories per
kilogram of body weight per day, compared with
100 to 110 needed by a term infant.
 Protein requirements are 3 to 3.5 g per kilogram
of body weight, compared with 2.0 to 2.5 for a
term newborn.
 Feedings may be as small as 1 or 2 mL every 2 to
3 hours.
Gavage Feeding
 Gag reflex - occurs at 32 weeks
 Sucking and swallowing – occurs at 34 weeks
of
 Offer pacifier to strengthen sucking reflex during
gavage feeding
 Inability to digest this way is also a sign that
necrotizing enterocolitis, a destructive intestinal
disorder
for
Breastmilk
 Immunologic properties of breast milk play a
role in preventing necrotizing enterocolitis
 Breast milk from mother high sodium content
 The mother who wants to breastfeed can
manually express breast milk for her infant’s
gavage feedings.
 expressed breast milk can be frozen for safe
to transport and storage.
Formula
 Needs to supplement with iron, calcium and
phosphorus and electrolytes such as sodium,
potassium and chloride.
 Vit A- for improve healing and reduce lung
disease
 Vit E- prevents haemolytic anemia
 The caloric concentration of formulas used for
preterm infants is usually 24 cal/oz, compared
with 20 cal/oz for a term baby.
 As with a term neonate, vitamin K should be
administered at birth. However, the amount
administered is more often 0.5 mL instead of 1
mL because of the infant’s small size.
Ineffective thermoregulation r/t
immaturity
 They have large surface area per kilogram of
body weight and they don’t flex thus increasing
the rapid cooling from evaporation
 Limited amount of brown fat, cannot shiver and
cannot sweat.
 Keep them radiant warmer , incubators or do
skin to skin contact
Risk for infection related to immature
defences in the preterm infant
 Skin is easily traumatized plus have difficulty
producing phagocytes as well as deficiency in
IgM –
 do not share linens with other infants ,
 staff members should be free of infection ,
 wear gowns and do hand washing .
Risk for impaired parenting r/t
interference with patient – infant
attachment resulting from
hospitalization of infant at birth.
 They need as much attention as a term newborn
- rock , sing and talk to them to develop a sense
of trust
 Parents need to come to terms with their
feelings of disappointment or guilt .
 Handle and stoke the infant in the incubator, let
the mother hold the baby before and after
gavage feeding.
 Primary nursing or case management with one
nurse helps reduce the number of people who
contact the parents
 Try to welcome siblings to build family unity.
Deficient diversional activity (lack
stimulation) r/t preterm infant rest
needs
 They need to conserve energy for growth and
respiratory function – organize procedure to
maximize the amount of rest available to the
infant.
 Be sensitive to move objects and noise away
from the infant to avoid overstimulation
 Look directly into the infant in the
straightforward position as much as possible to
provide stimulation of a human face
 Provide a talk time – words spoken softly but
clearly into their ears
 Provide human contact – stroke their back and
their head.
Risk for disorganized infant behaviour
r/t prematurity and environmental
overstimulation
 Developmental care( care designed to meet the
specific needs of each infant)can lead to
increased weight gain and decrease crying and
apnea spells in preterm infants
 Dim the lights , cover an incubator, turning to
sides and contain the body using rolled towels
(nesting)
Parental health – seeking behaviour The Postterm Infant
r/t infants needs for health  Postterm infant is one born after the 42nd week

maintenance.
 Before NICU discharge, parents needs to learn
and practice special methods of care basic
immunization , plotting of child's weight and
height according to the baby’s adjusted age,
evaluate growth and development milestones.
of a pregnancy.
 Most nurse-midwives and obstetricians
recommend inducing labor at 2 weeks postterm
to avoid postmature births
 They are at risk because the Placenta only
functions for 40 weeks.
 it seems to lose its ability to carry nutrients
effectively to the fetus.
 A fetus who remains in utero with a failing
placenta may die or develop postterm
syndrome:
o dry, cracked, almost leather-like skin
from lack of fluid, and absence of vernix.
 The amount of amniotic fluid may be less at birth
than normal, and it may be meconium stained.
 a sonogram is usually obtained to measure the
biparietal diameter of the fetus. A nonstress test
or complete biophysical profile may be done to
establish whether the placenta is still
functioning adequately.
 Cesarean birth may be indicated if a nonstress
test reveals that compromised placental
functioning may occur during labor.
 hypoglycemia may develop because the fetus
had to use stores of glycogen for nourishment
in the last weeks of intrauterine life.
 Subcutaneous fat levels may also be low, having
been used in utero. This can make temperature
regulation difficult, making it important to
prevent a postterm infant from becoming chilled
at birth
 Polycythemia may have developed from
decreased oxygenation in the final weeks. The
hematocrit may be elevated.
 ILLNESS IN THE NEWBORN
Respiratory Distress Syndrome (RDS)
 Formerly hyaline membrane disease, is most
often seen in newborns born prematurely.
 Other causes: meconium aspiration syndrome,
sepsis, a newborn who is slow to transition to
extrauterine life and pneumonia
Assessment
 Difficulty initiating respiratory at birth
 Subtle signs of RDS (symptom free)
o Low body temp
o Nasal flaring
o Sternal and subcostal retractions
o Tachypnea
o Cyanotic mucous membranes
 Expiratory grunting caused by closed glottis—
an attempt to increase pressure in alveoli
 Fine rales and diminished breath sounds—poor
air entry
 Increased distress
o Seesaw respiration - on inspiration, the
anterior chest wall retracts and the
abdomen protrudes; on expiration, the
sternum rises
o Heart failure
o Pale, gray skin
o Periods of apnea
o Bradycardia
o Pneumothorax
 Diagnosis of RDS: grunting, central cyanosis in
room air, tachypnea, nasal flaring and
retractions, chest radiograph reveal haziness in
the lungs, respiratory acidosis
Therapeutic management
 RDS can be largely prevented by the
administration of surfactant at birth into an
ET tube by a syringe or catheter (lung
lavage)
 It is important an infant’s airway not be
suctioned for as long a period as possible
after administration of surfactant to avoid
suctioning the drug away.
 Oxygen administration
o Can be administered via simple cannula
mask, continuous positive airway
pressure (CPAP) or assisted ventilation
with positive end expiratory pressure
(PEEP)
 Ventilation
o Normal ventilation inspiration shorter
than expiration
o RDS infant reversed I/E ratio 2:1 to
deliver to a stiff, non-complaint lung
o Complications: pneumothorax and
impaired cardiac output—decreased
blood flow though the pulmonary artery
from increased lung pressure
 another method of increasing pulmonary blood
flow is by using muscle relaxants. Pancuronium
(Pavulon) can be administered intravenously
 its effect can be interrupted by the
administration of atropine
 Nitric oxide
o A potent vasodilator but does not cause
decrease in vascular tone
 Extracorporeal Membrane Oxygenation
(ECMO)
o first developed as a means of oxygenating
blood during cardiac surgery.
o blood is removed from the baby by gravity
using a venous catheter advanced into the
right atrium of the heart. The blood
circulates from the catheter to the ECMO
machine, where it is oxygenated and
rewarmed.
 Liquid Ventilation
o Liquid ventilation involves the use of
perfluorocarbons
o As the liquid moves into a lung, oxygen
is carried along with it; as the liquid
spreads over all lung surfaces, an
exchange of oxygen occurs
 Supportive care
o Keep warm, provide hydration and nutrition
with IV fluids and glucose or gavage feedings
Transient Tachypnea of the Newborn
(TTN)
 At birth, a newborn may have a rapid rate of
respirations, up to 80 breaths per minute when
crying, caused by retained lung fluid.
 within 1 hour, however, this rapid rate slows to
between 30 and 60 breaths per minute. In
 Mild retractions but not marked cyanosis
 mild hypoxia
 hypercapnia may be present.
 Feeding is difficult because the child cannot suck
and breathe this rapidly at the same time.
 Transient tachypnea may reflect a slight
decrease in production of phosphatidyl glycerol
or mature surfactant but is a direct result of
retained lung fluid.
 Transient tachypnea occurs more often in
infants who are born by cesarean birth, in
infants whose mothers received extensive fluid
administration during labor, and in preterm
infants.
 Infants born by cesarean birth are probably
more prone to develop this form of respiratory
distress because the thoracic cavity is not
compressed as it is in vaginal birth, so less lung
fluid is expelled than normally.
 Watch for beginning signs of a more serious
disorder, because a rapid respiratory rate is
often the first sign of respiratory obstruction.
 Oxygen administration may be necessary.
 Transient tachypnea of the newborn peaks in
intensity at approximately 36 hours of life and
then begins to fade. Typically, by 72 hours of
life, it spontaneously fades as the lung fluid is
absorbed and respiratory activity becomes
effective.
Meconium Aspiration Syndrome
 Meconium is present in the fetal bowel as early
as 10 weeks’ gestation.
 If hypoxia occurs, a vagal reflex is stimulated,
resulting in relaxation of the rectal sphincter.
 This releases meconium into the amniotic fluid.
 Babies born breech may expel meconium into
the amniotic fluid from pressure on the
buttocks.
 Meconium can cause severe respiratory distress
in three ways:
o it causes inflammation of bronchioles
because it is a foreign substance;
o it can block small bronchioles by
mechanical plugging; and
 o it can cause a decrease in surfactant
production through lung trauma.
 secondary infection of injured tissue may lead to
pneumonia.
 Hypoxemia, carbon dioxide retention may occur
Assessment
 difficulty establishing respirations at birth
 he Apgar score is apt to be low. Almost
immediately, tachypnea, retractions, and
cyanosis occur.
 an infant should be suctioned with a bulb
syringe or catheter while at the perineum,
before the birth of the shoulders, to avoid
meconium aspiration.
 Do not administer oxygen under pressure (bag
and mask) until an infant has been intubated and
suctioned, so that the pressure of the oxygen
does not drive small plugs of meconium farther
down into the lungs, worsening the irritation
and obstruction.
 air trapping may also cause enlargement of the
anteroposterior diameter of the chest (barrel
chest).
 A chest radiograph will show bilateral coarse
infiltrates in the lungs, with spaces of
hyperaeration (a peculiar honeycomb effect).
Therapeutic Management
 Amnioinfusion can be used to dilute the amount
of meconium in amniotic fluid and reduce the
risk of aspiration. Used only in distress.
 CS
 After birth and tracheal suction, infants may
need to be treated with oxygen administration
and assisted ventilation.
 Antibiotic therapy may be used to forestall the
development of pneumonia as a secondary
problem.
 Surfactant may be administered to increase
lung compliance.
 pneumothorax or pneumomediastinum- caused
by noncompliant lung tissue causing high
inspiratory pressure.
 Because of increased pulmonary resistance, the
ductus arteriosus may remain open,
 causing blood to shunt from the pulmonary
artery into the aorta, compromising cardiac
efficiency and increasing hypoxia.
Apnea
 Apnea is a pause in respirations longer than 20
seconds with accompanying bradycardia.
 preterm infants have periods of apnea as a result
of fatigue or the immaturity of their respiratory
mechanisms.
 secondary stresses, such as infection,
hyperbilirubinemia, hypoglycemia, or
hypothermia, tend to have a high incidence of
apnea
 Gently shaking an infant or flicking the sole of
the foot often stimulates the baby to breathe
again,
 To help prevent episodes of apnea, maintain a
neutral thermal environment and use gentle
handling to avoid excessive fatigue.
 using indwelling nasogastric tubes rather than
intermittent ones can also reduce the amount
of vagal stimulation.
 careful burping also helps to reduce this effect.
 Theophylline or caffeine sodium benzoate may
be administered to stimulate respirations.
Sudden Infant Death Syndrome (SIDS)  They need this assurance if they are to plan for
other children.
 Sudden unexplained death in infancy.
o Infants of adolescent mothers, Apparent Life-Threatening Event
o infants of closely spaced pregnancies,
 An episode of infants discovered cyanotic and
o and underweight and preterm infants.
limp in their beds but have survived after mouth-
 Prone to SIDS are infants with
to-mouth resuscitation by parents.
bronchopulmonary dysplasia, twins, Native
 Apnea monitoring in place, an alarm sounds
American infants, Alaskan Native infants,
when the neonate experiences a period of
economically disadvantaged black infants
apnea of 20 seconds or longer or a decreased
 The peak age of incidence is 2 to 4 months of
heart rate below 80 beats per minute
age
 parents are going to use an apnea monitor at
 Contributing factors include:
home, make certain they will be able to hear it
o Viral respiratory or botulism infection
in all parts of the house or apartment.
o Pulmonary edema
 Having someone periodically review with them
o Brain stem abnormalities
what steps to take should the alarm sound
o Neurotransmitter deficiencies
(jiggle the baby, begin mouth-to-mouth
o Heart rate abnormalities
resuscitation, call the emergency response
o Distorted familial breathing patterns
personnel) can be very comforting.
 do not appear to make any sound as they die,
which indicates they die with laryngospasm. Periventricular Leukomalacia
 autopsy often reveals petechiae in the lungs
 abnormal formation of the white matter of the
and mild inflammation and congestion in the
brain
respiratory tract.
 caused by an ischemic episode that interferes
 American Academy of Pediatrics made its
with circulation to a portion of the brain.
recommendation to put newborns to sleep on
o Phagocytes and macrophages invade the
their back and with a pacifier, the incidence of
area to clear away necrotic tissue.
SIDS has declined
o What is left is an abnormality in the white
 Many parents experience a period of somatic
matter of the brain
symptoms that occur with acute grief, such as
 most frequently in preterm infants who
nausea, stomach pain, or vertigo.
experience cerebral ischemia.
 Parents should be counseled by a nurse or
 infants may die of the original insult; they may
someone else trained in counseling at the time
be left with long-term effects such as learning
of the infant’s death; it helps if they can talk to
disabilities.
this same person periodically for however long it

takes to resolve their grief.
 Reading that their child’s death was
unexplained can help to reassure parents the
death was not their fault.