1
Q
What is SGA, LGA and IUGR?
A
- LGA: infant is above the 90th percentile on a standard growth chart
- SGA: infant is below the 10th percentile on a standard growth chart
- IUGR: refers to the deviation and reduction in expected fetal growth pattern
2
Q
When is should term IUGR used?
A
- term IUGR should be used when there is evidence of abnormal genetic or environmental influences affecting growth.
- Thus, infants can be SGA without IUGR, and infants can suffer from IUGR and not be SGA
3
Q
What is the common cause of IUGR?
A
- Uteroplacental insufficiency
- fetus will respond to a lack of oxygen supply and nutrients first by decreasing subcutaneous tissue, then by decreasing in length, lastly the head and brain growth will be affected
4
Q
What are the two types of IUGR?
A
symmetrical: occurs early in pregnancy
- This type of growth restriction occurs early in pregnancy and is associated with a decreased number of fetal cells.
- It is marked by inadequate growth of the head, body, and extremities.
- Infants are born with fewer brain cells and tend to have poorer outcomes.
- Etiologies include genetic or chromosomal causes, early gestational intrauterine infections (TORCH), and maternal alcohol use.
Asymmetrical: occurs in the third trimester
- This type of growth restriction usually occurs early in the third trimester and is associated with impaired growth of the body, with normal growth of the head and extremities
- It is the result of failure of the cells to increase in size, resulting in less fat and smaller abdominal organs.
- This is due to extrinsic influences that affect the fetus later in gestation, such as preeclampsia, chronic hypertension, and uterine anomalies.
5
Q
What kind of cognitive/learning problems is caused with IUGR in full term infant? preterm infant?
A
- full term: show more language problems, learning disabilities, neuromotor dysfunction, hyperactivity, and attention and behaviour problems than full-term infants of an average size.
- Preterm infants: who are also IUGR demonstrate the disadvantages of both prematurity and IUGR, showing higher rates of major disability and learning disability
6
Q
What are 4 problems that infants are at risk for by being IUGR/SGA?
A
- hypoxia due to placenta insufficiency
- hypothermia due to small size and reduced brown fat stores
- hypoglycemia due to reduced hepatic glycogen stores
- polycythemia due to increased erythropoiesis (too many RBC/ increase in Hgb levels)
7
Q
What is apnea?
A
- Apnea is defined as a non-breathing episode lasting longer than 20 seconds and accompanied with cyanosis and/or bradycardia
8
Q
What are the two types of apnea?
A
- primary apnea: refers to apnea that is not associated with any other diseases (for example, apnea of prematurity)
- secondary apnea: may be associated with a particular disease or in response to a procedure
***primary apnea responds to the initial steps of Neonatal Resuscitation Program (NRP), whereas secondary apnea does not respond to stimulation, drying, or suctioning and requires initiation of intermittent positive pressure ventilation (IPPV).
9
Q
What is apnea of prematurity?
A
- severity of apnea attacks in premature infants correlates with gestational age
- apnea occurs most frequently during the sleep state and is especially prevalent during active sleep
10
Q
What two characteristics of sleep states of premature infants put them at risk for developing apnea?
A
- Active sleep, or REM sleep, is the predominant sleep state of premature infants
- infants less than 32 weeks spend 80% of their time asleep.
11
Q
How is peripheral catecholamines a contributing factor in apnea in premature infant?
A
- Premature infants have a decreased amount of peripheral catecholamines (epinephrine and norepinephrine), and this has also been implicated as a cause of apnea.
- When infection is present, catecholamine stores are further depleted, putting infected premature infants at a very high risk for developing apnea
12
Q
How is muscle fatigue a contributing factor in apnea of prematurity?
A
- Premature infants have very compliant chest cages and less compliant lungs than full-term infants, and this means increased work of breathing for premature infants
13
Q
What is secondary apnea?
A
- Rather than being due to prematurity, apnea may be the first sign of an underlying disorder.
- When an infant suddenly starts having apneic spells, it is important to investigate for possible underlying disorders before jumping to the diagnosis of apnea of prematurity and initiating drug therapy.
- Apnea seldom occurs in first 24 hours of life, even in premature infants.
- Therefore, the appearance of apneic spells in the first 24 hours is usually a sign of an underlying disorder.
- Apnea is rare in infants of greater than 34 weeks gestation and needs to be promptly investigated
14
Q
What are the order sequence of assessment and intervention that should be proceeded when responding to infant who is apneic/bradycardia?
A
- look at the infant: if infant looks fine then check monitor, the leads.
IF infant not fine then
- check breathing and if infant apneic then
- provide gentle stimulation by rubbing infant back/foot.
- check airway (ensure its patent): sniffling position.
IF that didnt work then provide intermittent positive pressure ventilation (IPPV) with a bag and mask
check heart rate:
once infant breathing check HR, if below 100 bpms
- continue with or start with PPV with bag and mask.
once infant breathing and HR>100 then
- check colour and oxygen saturation: If pale or cyanosed with low oxygen saturation, provide oxygen (~10% higher than what the infant is receiving).
As long as the heart rate is greater than 100 and the infant is breathing, bag and mask ventilation is no longer required.
15
Q
How is sniffling position achieved?
A
- gently lifting the chin to slightly extend the neck.
16
Q
What are some potential reasons for premature infant apnea and bradycardia (3)?
A
- prematurity—CNS immaturity, sleep patterns, catecholamine deficiency, fatigue
- positioning—sometimes infants obstruct their airways when their chin falls to their chest or when their necks are hyperextended
- hypoxia—depresses the respiratory centre anemia—insufficient oxygen carrying capacity
- sepsis—all premature infants have the potential to develop infections because of the immaturity of their immune systems
- neurologic—depressed respiratory centre
- hypothermia—Austin is very small with very little ability to self-regulate his temperature
- hypoglycemia—Austin will have low glycogen stores because of prematurity and because of his SGA
- gastro-esophageal reflux
17
Q
What would a nurse assess further about infant to determine cause of apnea (3)?
A
- oxygen: pulse oximetry, Hgb, and Hct
- check infants position
- complete set of vital signs, especially temperature
- blood work: blood cultures, CBC/differential, electrolytes, glucose
- tone, level of alertness
18
Q
What would you do if you notice infant is not breathing (the steps)
A
- quickly opens the porthole door and
- gently rubs infants back but infant doesn’t respond.
- turns infant over onto his back and places him in a sniff position. With this, infant opens his eyes, gasps weakly, and begins breathing.
- will make note of infants heart rate and colour are satisfactory and
- then will turn infant back on his stomach
19
Q
What is Methylxanthines used for?
A
- Methylxanthines (caffeine citrate, theophylline, aminophylline) are the primary treatment option for apnea of prematurity (AOP)
- They are cardiac, respiratory, and CNS stimulants and smooth muscle relaxers, with the effect on apnea being related to the CNS stimulation
20
Q
What are 3 reasons why caffeine citrate the drug of choice for apnea of prematurity (AOP)?
A
- once a day dosing,
- earlier onset of action,
- wide therapeutic range,
- no alterations in cerebral blood flow
- fewest side effects
21
Q
What are the nursing care when monitoring infants respiratory status when administering caffeine citrate?
A
- Monitor work of breathing, oxygen saturation, hemoglobin, ventilation, blood gases, colour, HR, RR, air entry, chest movement.
- Monitor apnea: frequency, duration, stimulus required, oxygen saturation, and HR.
- Administer caffeine citrate and ensure correct dosage for weight.
- Maintain saturations between 88% and 95%.
- Ensure adequate volume and hemoglobin.
- Ensure developmentally supportive and family-centred care.
22
Q
What are the functions of mature digestive system?
A
- salivary glands: moistens and lubricates food
- mouth: break up food particles
- pharynx: swallows
- esophagus: transports food
- stomach: stores and churns food
- liver: breaks down and builds up molecules
- gall bladder: stores biles
- pancreas: hormones regular blood glucose level
- small intestine: completes digestion, absorbs nutrients
- large intestine: reabsorbs water. forms and store feces
- rectum: stores and expels feces
- anus: opening for elimination of feces
23
Q
How are the GI tracts of preterm infants immature (4)?
A
The GI tracts of infants are immature because:
- they have delayed gastic emptying,
- decreased enzyme activity,
- decreased parastalsis,
- decreased normal flora.
24
Q
What type of infants should be NPO and not fed at all (3)?
A
infants who:
- are asphyxiated with persistent hypoxemia and metabolic acidosis
- are hypotensive with or without the need for BP medications
- are persistently and severely hypoxemic
- are clearly septic with evidence of necrotizing enterocolitis (NEC)
- have congenital anatomic GI anomalies
- may require surgery, especially GI surgery
25
What does early enteral feeding important in neonatal management supports (3)?
supports:
- GI development,
- somatic growth,
- metabolic homeostasis,
- prevention of infection,
- neurological development, and
- future health
26
If premature infant is NPO and are not on full feeds, what IV nutrition should be given?
- D10W: provide sugar and water but does not provide protein, fat or electrolytes
- If an infant will be NPO for an extended period, TPN should be given.
** does not have adequate suck/swallow/breathe coordination as this does not develop before 33–36 weeks gestation
27
If infant cant be breastfed or bottle feed, whats another feeding option?
- can be fed by an oral or nasal gastric tube
- Infants fed by a gastric tube are at risk for intolerance because they have no control over the amount or frequency of feeding.
- They must be closely observed for tolerance of feeds.
28
What is donor milk?
- Donor milk is breastmilk that has been pasteurized and
- usually frozen for distribution to hospital units.
29
What 2 reasons would an infant need to be started on donor human milk (DHM)?
- low supply of maternal breastmilk or
- the mother has chosen not to pump
** recognized that DHM is the best replacement for mother’s milk, with infant formula offering a third option if needed.
30
What is informal milk sharing?
- when milk is acquired by the parents and it has not been pasteurized or screened by a regulated source.
- the Canadian Paediatric Society does not endorse informal milk sharing as there are several risks associated with giving milk that has not been through a full screening and pasteurizing process
31
What are some indications for initiating IV therapy in infants (3)?
- to maintain fluid, electrolyte, and glucose balance when oral fluids are not tolerated or are contraindicated, or as an adjunct to intermittent feeding
- to provide adequate nutrition for growth (usually via TPN)
- to administer medications
- to administer blood or blood products
32
What are 3 complications of IV therapy for infants?
- Extravasation/ infiltration: most frequent complications
- Infection/Septicemia: more serious complications
- Total Fluids: close monitoring to prevent fluid overload or dehydration
33
What is extravasation? 3 Signs of extravasation?
- infiltration of intravenous solution into the tissues is usually caused by the dislodgement of the IV catheter.
The signs include:
- swelling,
- edema,
- redness, and/or
- blanching at the site.
- site may be cool to touch
- painful for the infant when touched.
34
Why are premature infant skin described as "paper thin"?
- immaturity of the skin.
- the veins are very thin and friable with very little or no muscle support.
- They move easily and are very fragile.
- skin thin and unable to lend support to the blood vessels
35
What are 2 reasons that make extravasation /infiltration most frequent complication with IV therapy for infant?
- immaturity of the circulatory system
- immaturity of the skin
36
What assessment are included to prevent infiltration of IV therapy? Treatment?
- assessment of the IV site at least hourly,
- adequate taping of the device with transparent dressing/plastic tape so the site is clearly visible
- possibly restraining the limb
Treatment
- to discontinue the IV at the earliest sign of infiltration and elevate the extremity.
- This is to prevent IV burns and scar formation that often results from infiltration.
- Use of moisture, heat, or cold is not recommended because the tissue is vulnerable to further injury at this point
37
Why is it important to elevate extremity after discontinuing IV therapy at the earliest sign of infiltration (2)?
Elevating the infiltrated areas:
- increases lymphatic and venous drainage,
- helping to decrease edema.
38
What is Hyaluronidase use for?
- helpful treatment if it is administered within one hour of extravasation.
- This medication is an enzyme that destroys extracellular barriers, allowing rapid diffusion and absorption on the infiltrated fluid (not for use with vasoactive drugs).
- It is injected subcutaneously around the periphery of the site.
39
How can infection occur during IV therapy? Prevention?
- Infection or septicemia occurs when bacteria, fungus, or viruses invade the bloodstream through the IV site.
Prevention
- proper hand washing,
- following unit procedures for skin preparation,
- changing and accessing IV solutions as per unit policy
40
How are total fluids ordered for infant on IV therapy?
- Infants are ordered a certain amount of fluid per kilo per day to meet their daily requirements of nutritional support
- Excessive or insufficient fluid amounts will result in either fluid overload or dehydration, and both will not meet the infant’s specific nutritional requirements.
41
What are some preventions of ensuring sufficient fluids being given to infant via IV therapy?
- Excessive or insufficient infusion of IV fluid can be a result of a malfunctioning infusion pump or an incorrectly set rate.
Preventions:
- checking the infusion pump at least hourly for the amount of fluid infused,
- ensuring the correct rate is set on the infusion pump, and
- checking the physician’s order for total fluids.
42
What are some nursing care aimed at monitoring infants nutritional requirements (3)?
- Monitor serum glucose for all at-risk infants: SGA, perinatal asphyxia, RDS, hypoxia, infant of diabetic mother (IDM).
- Ensure accurate fluid requirements based on weight.
- Meet fluid and caloric needs with N/G or O/G and IV.
- Slowly increase feeds and decrease IV.
- Monitor tolerance of feeds closely.
- Monitor for signs of NEC.
- Monitor IV site, rate, and type of fluid.
- Minimize glucose utilization by minimizing pain, stress, and handling.
43
What is TPN composed of (5)?
- electrolytes,
- lipids
- minerals,
- trace elements
- vitamins,
44
What are some risks/complications of TPN (3)?
- issues with glucose metabolism (hypo/hyperglycemia),
- problems with amino acid metabolism,
- cholestasis (flow of bile from your liver is reduced or blocked)
- hyperlipidemia, and
- infections
45
Why do premature infants <32 weeks likely require 2-3 weeks of IV therapy to maintain nutritional status?
- have immature gastrointestinal systems.
- While oral feeds (OG/NG) may be started, the progression to fully oral feeds in premature infants is generally quite slow.
- therefore, IV fluids are used to supplement oral feeds --> to help maintain fluid and nutritional status.
46
What assessment of infants IV therapy should nurse include? how often to check IV site?
- check IV site for redness, swelling and blanching, pain, temperature, leaking
- check around the site, looking at the tapes, the limb board, position
- check physician’s order for total fluids for the day and calculate the IV rates accordingly
- check for correct solutions, rates, and alarms on infusion pumps
- check the IV site at least hourly and more often if concerned about its appearance
- check the site frequently while administering medications
47
What is the formula to calculate hourly IV rate (mL/hr)?
- Formula for calculating total daily fluids is total fluids ordered × weight in kilograms.
- To calculate the hourly rate, you then divide by 24.
48
Why would a nurse be concern about infants slightly distended belly with NG (EBM)
- feeding infant does carry some risk.
- infant may not tolerate enteral feeds because they are premature.
- All premature infants being fed enterally must be closely monitored for tolerance.
49
What are some possible reasons for infant developing signs of feeding intolerance (3)?
- immaturity of the gastrointestinal system is the most common cause of intolerance
- hypoxia
- sepsis
- necrotizing enterocolitis
- side effect of caffeine citrate
- congenital anomalies
50
Why is expressed breastmilk the best choice for feeding premature infant?
- Breast milk is immunologically and nutritionally superior to formula and
- it is also easier to digest.
51
What is the purpose of trophic feeds / minimal enteral nutrition /gut priming /early hypocaloric feeding? 4 benefits?
- trophic feeding is the practice of feeding very small volumes (nutritionally insignificant) of milk in order to stimulate and supply nutrients to the developing gastrointestinal tract of the preterm
- early initiation of low-volume enteral feeding
- This early enteral feeding should be started within the first two days of life and be given in small volumes every 4–6 hours for several days.
- Trophic feeds are most effective with colostrum and breast milk
Trophic feeds have been shown:
- promote GI development,
- stimulate gut hormones,
- improve blood flow and
- support microbial flora.
- No increase in the risk for NEC has been shown with trophic feeds.
- earlier achievement of full enteral feedings,
- improved weight gain,
- decreased sepsis,
- improved bone mineralization and
- shorter hospital stays.
52
What is Necrotizing enterocolitis (NEC)?
- a disease that primarily affects premature infants and
- is the leading cause of death due to gastrointestinal disease in preterm infants
- a progressive disease of the gastrointestinal tract involving inflammation, infection, and necrosis of the bowel tissue
- disease of the intestinal tract in which the tissue lining the intestine becomes inflamed, die
53
What are the prenatal factors that increase the risk for NEC (3)? Perinatal factors (3)? Neonatal care factors (3)?
Prenatal:
- Genetics
- Chorioamnionitis
- Intestinal immaturity
- Changes in microvascular tone
- Exposure to illicit drugs
- Placental issues
Perinatal:
- Low gestational age
- Low birthweight
- Abnormal microbial colonization
- Stress at birth
- Perinatal events (abruption)
- Impaired transition
Neonatal care factor:
- Environmental stressors
- Respiratory support
- Feeding type (formula increased risk by 6.4 times)
- Pharmacological interventions (for example, indomethacin)
54
What is the difference of development of NEC in preterm and full term infants?
Preterm infants:
- vulnerability arising from prematurity
- lack many important GI defense mechanisms
- delayed enteral feeding,
- early exposure to broad spectrum antibiotics,
- formula feedings
Full term infants:
- related to vulnerability arising from the transition to extrauterine life
- Asphyxia decreases blood flow to the gut, and if severe enough, can lead to ischemia and necrosis.
55
What are some prevention of NEC (3)?
- early exposure to colostrum,
- skin-to-skin contact,
- developmentally supportive care,
- feeding breastmilk only and
- managing acid-base balance and hypoxia
56
What is oral immune therapy (OIT)?
- oropharyngeal administration (not enterally) of breast milk (preferably colostrum) in such small volumes that the infant does not need to swallow
57
How is oral immune therapy (OIT) given?
- A small amount of milk (~0.1 - 0.2 mL divided between two cheeks) is placed on the oral mucosa in the buccal cavity for absorption.
- A sterile cotton swab can be used to gently "paint" the inside of the mouth including the tongue, gums, and buccal area, approximately Q 3-4H.
58
What are the 3 primary rationales for the use of human milk for oral care?
- Human milk is a powerful antimicrobial agent, and by coating the infant’s mouth with milk, a front-line defense is provided.
- Human milk is a rich source of cytokines, and these cytokines may be absorbed through the infant’s buccal mucosa, thus positively impacting the infant’s immune system.
- Human milk has a sweet flavouring, therefore oral care with human milk provides a positive oral experience.
59
Why is oral immune therapy (OIT) done (2)? What are benefits of OIT (3)?
- a way to stimulate the development of the neonatal immune system
- infants who are unable to feed orally can still receive some of the immunologic benefits of breast milk in a safe and feasible way
Benefits
- decrease the risk of NEC
- decrease the risk of sepsis
- decrease the risk of ventilator associated pneumonia (VAP)
- increase earlier attainment of full enteral feeding
- increase growth
- increase breastfeeding outcomes
- enhance maturation of oral feeding skills
60
What is a strong motivator for mothers to keep building their milk supply for infant?
- Maternal and family participation in human milk oral care
61
What are the benefits of probiotics in NICU (3)?
- reduce the incidence of NEC and
- reduce all-cause mortality in preterm infants
- shorter duration of hospitalization,
- increased weight gain,
- less feeding intolerance and
- reduced time to reach full enteral feeds
62
What gestational age/ weight of preterm infant is probiotics recommended for?
recommended in preterm infants:
- less than 37 weeks gestational age (preterm)
- less than 2,500 grams (LBW)
63
When should probiotics be started and for how long?
- frequently started with the initiation of feeding or at 48 hours of age
- with a duration of at least two weeks or as long as the infant is judged to be at risk for NEC
64
How is probiotics be given?
- administered either orally or via a feeding tube after mixing with a small amount of sterile water, human milk, or formula just prior to administration.
- As probiotics contain live bacterial cultures, they should be kept refrigerated and handled aseptically
65
What does kangaroo mother care (KMC) involves?
- the mother acting as the incubator for the infant, providing warmth, nutrition, and stimulation until the infant is close to the maturity of a term infant and able to tolerate extrauterine life.
- The infant is placed skin-to-skin in an upright position between the mother’s breasts day and night, exclusively (or nearly exclusively) breast fed, and
- discharged early from the hospital to continue KMC at home
66
What is kangaroo care (KC) or skin to skin contact (SCC)?
- to describe intermittent skin-to-skin contact with the infant’s mother or other caregiver
67
What are the benefits of skin to skin?
- improved attachment and bonding, and
- decreased maternal and infant stress
- improve breastfeeding rates, length of breastfeeding, and volume of breast milk produced
- important, safe, and effective non-pharmacological intervention to reduce pain in infants
- promotes physiological stability,
- improving cardiorespiratory stability,
- increasing glucose levels, and decreasing crying
- provides warmth,
- promoting thermoregulation,
- improves sleep, and
- stimulates the release of oxytocin in both the infant and the care provider
68
What are hand hugs?
- another way for families to connect with their infant
- one hand is gently placed on the infant’s head and another hand on the feet, bottom, or abdomen
69
What are the benefits of skin to skin for premature infant?
- improves self-regulation
- reduces stress
-facilitates neurodevelopmental
- maturation/improves neurological outcomes
- stability of vital signs
- improves attachment, bonding, and breastfeeding
- reduces pain
- decreases crying
- improves glucose levels
- improves sleep
- improves immune function/decreases risk of sepsis
- improves thermoregulation
- provides positive touch experiences
- positive sensory experiences: auditory, olfactory, vestibular, visual, tactile
- stimulates production and release of oxytocin
- promotes a healthy microbiome
- provides postural support
- supports motor development
- decreases mortality rates
70
What are the benefits of kangaroo care for mother?
- improves maternal infant bonding
- improves breast milk production
- stimulates oxytocin production
- improves parental confidence and competence
- decreases maternal stress and anxiety
- improves postpartum affection towards infant
- improves maternal mental health
- encourages close parental proximity
- strengthens sense of parental role identity
71
How will you as nurse collaborate with infant and mother to develop a plan of care?
- take time to listen to moms story/history
- listen to moms concerns and needs
- explore further what would work for mother
72
What is teen pregnancy associated with?
- increased mental health concerns, such as addiction and depression
73
What are infants of teen moms at risk for?
- being born low birth weight,
- premature,
- poor pregnancy outcomes.
74
How can potential problems for infants teen pregnancy be decreased (3)?
- proper nutrition and
- early prenatal care and
- proper supports,
75
What are some barriers to involvement teen fathers encounter (3)?
- lack of money,
- lack of parenting skills,
- unstable relationships with the mother or her family, and
- increased psychosocial stress and anxiety
76
What is family centred care?
- recognize that when we focus only on the problems, weaknesses, and vulnerabilities
- know what resources she has available to her
- find out about families’ strengths and capabilities as well as their vulnerabilities
- interactions aimed at strengthening families in ways that are unique to them and build on existing resources
- provide care to the infant and family as a whole.
77
An infant who has experienced asphyxia should be enterally fed within the first two hours of life?
false
- neonates with perinatal asphyxia, enteral feeding is often delayed fearing complications such as necrotizing enterocolitis (NEC) and feeding intolerance.
78
Secondary apnea is NOT responsive to stimulation in the delivery room. It requires IPPV.
true
79
What is SGA? Causes (2)? at risk for (3)?
- Birthweight of <10% plotted on growth chart
Causes:
- Can be due to genetics
- Small parents
SGA are at risk for:
- temperature instability,
- hypoglycemia,
- jaundice,
- feeding difficulties
80
Whats IUGR? risk factors for (3)?
- Defined as the rate of fetal growth below expected growth pattern
- Clinical features of malnutrition
- IUGR is usually diagnosed prenatally
- Two types: symmetrical & asymmetrical IUGR
- risk factors: hypothermia, hypoglycaemia, feeding difficulties, feeding intolerance (NEC)
81
What is the difference between symmetrical and asymmetrical IUGR?
symmetrical IUGR:
- Occurs earlier in gestation → associated with decreased number of fetal cells
- Inadequate growth of the head, body, and extremities
- Born with fewer brain cells
- Prognosis poor neurodevelopmental outcome
- causes: genetic factors, fetal factors, maternal factors
asymmetrical IUGR:
- Occurs later in gestation Impaired growth of the body, normal growth of head and extremities
- Usually due to placental insufficiency
- Prognosis is good due to normal brain growth
- causes: placental factors (pregnancy induced hypertension)
82
What should be assessed when monitoring growth (3)?
- Growth Charts (daily weight / weekly head & length )
- Look at the growth trend, not a single number
- Rate of weight gain over last 7 days
- Target rate of weight gain: 20-30 g/day
- Dietician involvement
83
Whats apnea? bradycardia? desaturation
- apnea: Pause in breathing for >20 seconds OR >15 seconds when accompanied with a bradycardia or desaturation
- Result of many physiological and/or pathological processes
- bradycardia: Heart rate slows at least 30 bpm
from resting heart rate (HR < 100). low resting HR can be normal for term infants
- desaturation: Oxygen saturation levels less than oxygen goals for at least 5 seconds
84
What causes apnea of prematurity (3)?
- ↓ sensitivity of central (brainstem) and peripheral (aortic arch) chemoreceptors for regulation and control of ventilation
- Responds to hypoxemia and hypercapnia with a brief increase in respiratory rate followed by respiratory depression →apnea
- Diaphragmatic fatigue (compliant rib cage & less compliant lungs → increase WOB → lacks reserves, easily tires out)
- More common when in REM sleep → 80% of the time spent sleeping → REM predominant sleep state
- Gradual decrease in all types of apnea during the first month of postnatal life
- May persist until 42wk
85
What are the 3 types of apnea?
Central
- Absence of breathing effort due to immature CNS
- Other causes: medication or illness
Obstructive
- Obstruction to the airway/cessation of airflow in the presence of continued respiratory effort;
- Blockage at level of larynx/pharynx
- Hyperextension/flexion
Mixed
- A period of central apnea, typically followed by airway obstruction
- Most frequent type among preterm infants
86
What are the incidence of AOP?
- Incidence decreases with increased gestational age
- Almost all infant <28 weeks gestation will experience AOP
- 50% born between 33 to 34 weeks will experience AOP
- Apneic spells stop in 92% of infants by 37 weeks CGA and > 98% by 40 weeks CGA
- Infants with CLD have delayed maturation of respiratory control which can prolong apnea
87
What is periodic breathing?
- Brief periods of apnea occur in short cycles (5 to 10 seconds)
- Not associated with heart rate changes or cyanosis
88
What should nurse do when assessing apnea?
- LOOK AT baby
- check history
- observe what is happening during apnea: active sleep, post feed, post handling, positioning, respond to stim, position change
- ensure to note length of apnea
- document
- monitor trends: having more apneic episodes, new or increasing?
- Accompanied by bradycardia or desaturation?
- Feeds? Emesis
- Position? Is chin touching chest?
- Resp support discontinued recently? Fatigued
- Sepsis – is your baby getting sick?
CBC, CRP, blood culture, possibly
lumbar puncture, urine culture, CXR
89
What do you do if an infant is having an apnea accompanied by a bradycardia lasting 10 seconds?
- look at baby, stim, reposition
90
What do you do if an infant is having an apnea, bradycardia, and desaturation and does not respond to stimulation?
- nrp
- nippv
91
What do you do if an infant is on NIV and desaturating?
- if on respiratory support, increase oxygen saturation
92
What are some for treatment for ABDs?
Investigation to exclude causes and treat precipitating factors
Support respiratory system
* CPAP, mechanical ventilation
Medication
* Caffeine citrate – stimulant for premature infants (apnea)
Other
* Treat the cause. Sepsis?
93
How long should infant be ABD free for before discharged home?
- ABD free for 5 to 7 days before discharge
94
What is apnea associated with for term infants?
- The incidence of apnea in term infant is 1 in 1000
Usually associated with serious identifiable causes:
- birth asphyxia
- IVH
- infection
- seizures
- medications
- congenital malformations
95
What is GER?
- GER: a return or backward flow of gastric contents into the esophagus with or without
regurgitation.
- GER is a normal physiologic occurrence
- Can occur several times a day
- Reflux in preterm infants is common (25-75% )
- The most common cure for reflux is maturation
and time
Medication (Ranitidine/Famotidine) is not
supported by evidence (risk/benefit)
* risks of gastric acid suppression→
* Increased GI infections
* bacterial overgrowth
* adverse bone health
* Increases risk of NEC
96
What is the management for GER?
- Emesis does not always mean intolerance
- Nursing considerations to help those more “spitty” babies?
- If on gavage feeds, place over pump (doctors order)
- Hold upright after feeds
- Place left lateral/prone for help with gastric emptying
- Make every oral experience positive – when baby is not showing feeding cues, STOP
- ++ negative oral experiences increases risk
of oral aversion
97
What is feeding intolerance?
- feeding intolerance is NOT GER
- feeding intolerance: Inability to digest enteral
feedings associated with persistent emesis
- Infants are typically advancing on enteral feedings or may have achieved full-volume feeds when symptoms develop
- More common in premature infants - poor GI motility in first few weeks of life
98
What should be done promptly if noticed feeding intolerance in term infants?
prompt investigations should be done for:
- Sepsis,
- malrotation,
- tracheoesophageal fistula,
- obstruction,
- imperforate anus, etc
99
What are some GI assessment (4)?
- Walk through assessment of the GI system
- Abdominal girth – increases more than 1cm/shift
- Aspirates- bilious, bloody? When do we check?
- Abdomen – taut? Firm? Blue? Guarding noted?
- Bowel sounds – hypoactive?
- Emesis – persistent? New onset?
- Bilious?
- Stools – bloody?
- Lethargic
Other clinical signs and symptoms:
- ABDs outside of infant’s baseline, lethargic, temp instability, sepsis??
100
What is the NEC continuum?
- tolerating feeds well and gaining weight
- tolerating feeds
- not tolerating due to immature gut
- acute NEC
- full blown NEC with perforation
- overwhelming sepsis, DIC, death
101
What are the reasons that we dont wait til term to feed infants (3)?
- No evidence supporting delaying enteral feeding
- Improve GI development
- Growth & development
- Somatic growth (HC, L, W)
- Prevent infection
- Reduce days on TPN
- Reduce nosocomial infections
- Reduces incidence of NEC
102
What is NEC?
- “Necrotizing” means the death of tissue
- "entero" refers to the small intestine
- "colo" to the large intestine
- "itis" means inflammation
- A gastrointestinal disease that primarily affects premature infants, NEC involves infection and inflammation that causes destruction/necrosis of the bowel or part of the bowel
103
What are the risk factor of NEC for premature infant? term infant? maternal factors?
prematurity:
- Lack gastric acid, digestive enzymes, mucous production & immunoglobulins
- Delay in establishing enteral feeding
- Early exposure to broad spectrum antibiotic
term infant:
- birth asphyxia→ decreased blood flow to the gut can lead to ischemia and necrosis
maternal factors:
- factors that reduce fetal gut flow: placental insufficiency (IUGR)
104
How is NEC prevented?
- Early exposure to colostrum
- Feeding breastmilk only
- Formula increases risk of NEC by 6.4 times
- Standardized feeding plans
- Avoid prolonged use of unnecessary antibiotics
- Managing acid-base balance and hypoxia
- Thorough assessments & monitoring to detect NEC early in disease process
105
What are sign and symptoms of NEC (4)?
- Lethargic (with/without respiratory distress)
- ABDs (new or increasing from “baseline”)
- Temperature instability
- Shock (bowel perforation)
- Baby acting “unwell”, “different”
- oliguria
- Abdominal distention – rapid increase in girth (1cm)
- Feeding intolerance - bilious vomiting
- Hypoactive or absent bowel sounds
- Metabolic acidosis
- Blood in stool (seen 25% of the time)
106
What is the treatment for NEC (3)?
Treatment depends on bowel involvement and severity of presentation:
- NPO: Total Parenteral Nutrition
- Abdominal decompression (gastric tube/repogle to low intermittent/continuous suction)
- Antibiotic therapy to prevent sepsis (no definitive infectious etiology is known to cause NEC)
- Respiratory and cardiovascular support
- Comfort/Pain control
107
What is Total parental nutrition (TPN)
- Is the practice of feeding a person intravenously, bypassing the usual process of eating and digestion
Consists of two solutions:
- Neonatal Primene
- Lipids
108
When is TPN used (3)?
- Prematurity. All infants <32 weeks or <1500g will benefit from TPN
- Delay in establishing adequate enteral nutrition
- Used in combination with feeding plan
- Acutely ill infants
- Unable to feed
Examples of unable to feed:
- Gastrointestinal tract anomalies, Infants requiring major surgery (BCW), HIE cooling, NEC, Bowel perforation
109
What is the goal of using TPN?
- Support a rate of postnatal growth similar to intrauterine growth
- Promote organ development necessary for extrauterine life
- Prevent nutrient deficiencies and avoid excesses
- Foster optimal neurological development
110
What are the components of TPN (7)?
- Carbohydrates: Dextrose
- Protein: Amino Acids
- Lipid: Essential fatty acids
- Electrolytes: sodium, potassium, chloride, phosphate, calcium, and magnesium
- Trace elements: zinc, copper, manganese, and chromium
- Multi-vitamins
- Medication: Ex. Heparin → prevent formation of fibrin sheath around catheter
111
What is carbohydrate dextrose?
- Carbohydrates provide energy for the body, especially the brain and the nervous system
- Carbohydrates are provided by dextrose
* 10% - typical starting point
* 7.5%
* 12.5% - max concentration peripherally
- Anything greater than 12.5% associated with phlebitis & infiltration (will need CVC or PICC line)
112
What is protein: amino acids?
- Protein required for growth and development (tissue repair)
- Early administration of amino acids:
- Minimize protein catabolism
- Aim: growth (with adequate calorie intake)
- The smaller the infant the higher protein
requirement
- Preterm infants have poor ability to absorb protein through stomach, pancreas or intestines
113
What is lipids?
- Provides essential fatty acids for cell membrane integrity & brain development
- Intralipids 20%: soybean emulsion
- SMOF 20%: mixture of lipids (Soy oil, MCT oil, Olive oil, Fish Oil)
- management of cholestasis (↑conj bili)
114
What are some TPN complications?
- Hyperlipidemia
- Hyperglycemia
- Sepsis in lines (Lines changes every 24 hours)
IV burns:
- Peripheral IV can go interstitial quickly
- IV burns can lead to necrosis of the skin and surrounding tissue causing permanent scaring
Hepatic system:
- jaundice most common & can be serious
- 2 to 6 weeks of TPN = liver dysfunction
- Transient liver dysfunction → lab results will show increased bilirubin
Pathogenesis is unknown:
- contributing factors probably include cholestasis and inflammation
- Cholestasis & increased bilirubin levels resolve gradually with enteral feeds & weaning off TPN
115
What are some TPN prevention with IV sites/burns?
- Hourly checks of site
- Ensure site is visible at all times
- If in doubt ask a colleague or remove it
- Check site before giving a medication
116
What is pain?
- Pain in the neonate is a traumatic event
* Consistent with neonatal brain imaging observations → pain is associated with poorer neurodevelopment
- Study by neuroscientists looked at neonatal pain in preterm children at age 7
- Early procedural pain in very preterm infants may contribute to impaired brain development
117
What are some painful procedures? prevention?
painful procedures:
*Heel poke
*IV start
*NG/OG insertion
* Lumbar puncture
* Catheterization
*Intubation
* X-ray
pain prevention:
- Non-pharmacological interventions: swaddling, skin to skin, NNS, breastfeeding, facilitative tucking
- Sweet tasting solution (breast milk or sucrose)
- Two people for all painful procedures
- Bundling interventions together
118
What is the sweet tasting solution?
Breastmilk (preferred):
- Shown to decrease procedural pain
- Administer drops on soother
Sucrose 24%
- Shown to decrease procedural pain
- Mechanism of action not well understood
- Dosage as per site policy
- Use in combination with other non-pharm interventions
- Administer 2 minutes prior to procedure, analgesic effect lasts 5 – 8 minutes
119
How is pain assessed in neonate? pain scale tool used in FHA?
- Neonates are unable to tell us they feel pain
- Use systematic approach and pain tools
- Observe behavioral and physiological responses
- Remember, a lack of behavioral responses does
not always indicate a lack of pain
- Every painful procedure is assessed and
documented
- Pain score before, during & after procedure
- Interpretation of pain is subjective → look at the
trend. Constant elevated pain scores? Treat
underlying issue
Neonatal Pain Agitation Scale and Sedation Scale (NPASS) – FHA
- Crying/irritability, behavior state, facial expression, extremities/tone, vital signs
