HIGH RISK

NEWBORN
AND FAMILY
Presented by:
Princess P. Barnuevo
Student, Master of Arts in Nursing

OVERVIE
W

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)

Care around birth gives a triple return on

investments by reducing maternal and
newborn deaths and stillbirths

The
The lives
lives of
of more
more than
than 3
3 million
million babies
babies and
and women
women could
could be
be saved
saved
each
each year
year with
with high
high coverage
coverage of
of quality
quality care
care around
around birth
birth and
and
care
care for
for small
small and
and sick
sick babies
babies

rce: Special analysis detailed in The Lancet Every Newborn Series - forthcoming

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
Ophthalmia

and newborn deaths

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

1 24 hours
st

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 an d
Mai n ta in i n g R e sp i rati o n s
Breathing

is initiated by the second

stage of labor.

Most

neonatal deaths within the first 2448 hours are primarily caused by
inability to initiate breathing.

Lung

functions only begins after birth.

19

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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20

Neonatal Care

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Airway & Breathing

Stimulate

crying by rubbing
Position properly- side lying /
modified t-berg
Provide oxygen when necessary

Neonatal Care

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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
Neonatal Care
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 IVC
3. 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.

STRUCTUR
E

APPROPRIA STRUCTUR FAILURE TO

TE TIME OF
E
CLOSE
CLOSURE
REMAINING

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)

Table 1.1 Structures at Birth and the Remnants

After its Obliteration

Fluid and
Electrolyte Balance
Principles

of Fluid Balance:

TBW = ICF + ECF

ECF = Intravascular + Interstitial

http://akramania.byetho
st11.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-ohnomd-phd/maintainingintracellular-hydrationwater.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
Bronchopulmonary Dysplasia
Dysplasia
Respiratory
Respiratory Distress
Distress Syndrome
Syndrome

Patent
Patent Ductus
Ductus Arteriosus
Arteriosus

Hypoxic-Ischemic
Hypoxic-Ischemic
Encephalopathy
Encephalopathy

VOLUME
OVERLOAD
and/or
EDEMA

I
R
T
S
RE

ED
T
C

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 efficiency

reduce oxygen use
protect enzyme function

reduce

calorie expenditure

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Challenges of thermoregulation
in Neonatal care
Prior

to delivery infants do not maintain

temperature independently
Infants in-utero temp is generally 0.5C
higher than mothers 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

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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

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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 Hypothermia
o

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