2. OUTLINE
INTRODUCTION
EPIDEMIOLOGY OF INFANT MORBIDITY AND
MORTALITY
FACTORS THAT DEFINE AN INFANT AS BEING HIGH
RISK
SPECIFIC HIGH RISK INFANTS AND MANAGEMENT
DISCHARGE PROTOCOLS FOR HIGH RISK INFANTS
COMPLICATIONS
CONCLUSION
REFERENCES
3. INTRODUCTION
The term high-risk infant refers to any baby
exposed to any condition that puts the
survival of the neonate at danger.
Such babies should be under close observation
by experienced physicians and nurses
About 10-20% of all births require special or
neonatal intensive care
Neonatal mortality largely depends on
birthweight and gestational age
4. INTRODUCTION
For any given duration of gestation, the
lower the birthweight, the higher the
neonatal mortality
For any given birthweight, the shorter the
gestational duration, the higher the neonatal
mortality
Most neonatal mortality occurs within the 1st
hours and days after birth
The highest risk of neonatal and infant
mortality occurs in infants who weigh <1,000
g at birth and whose gestation was <28 wk
5. INTRODUCTION
The lowest risk of neonatal mortality occurs
in infants with a birthweight of 3,000-4,000 g
and a gestational age of 39-41 wk
6. EPIDEMIOLOGY
In 2016, 4.2 million (75% of all under-five
deaths) occurred within the first year of life
The risk of a infant mortality was highest in
the WHO African Region (52/1000 live
births), over 6x higher than that in the WHO
European Region (8/1000 live births).
Globally, the infant mortality rate has
decreased from an estimated rate of
64.8/1000 live births in 1990 to 30.5/1000
live births in 2016
In Nigeria, the MICS puts infant mortality
rate at 70/1000 LB in 2017
7. EPIDEMIOLOGY
Neonatal mortality rates rise sharply for
infants weighing more than 4kg at birth and
for those whose gestational period is 42 wk or
longer.
The perinatal mortality of twins is about 4
times that of singletons
Triplet or higher-order births are associated
with an increased risk of death or
neurodevelopmental impairment when
compared with ELBW singleton and twin
infants
8. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
Demographic social factors
Maternal age <16 or >40 yr
Illicit drug - alcohol, cigarette use
Poverty
Unmarried
Emotional or physical stress
9. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
Past medical history
Genetic disorders
Diabetes mellitus
Hypertension
Asymptomatic bacteriuria
Rheumatologic illness (systemic lupus
erythematosus)
Immune-mediated diseases (immunoglobulin G
crossing placenta)
Long-term medication
10. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
History of previous pregnancy
Intrauterine fetal demise
Neonatal death
Prematurity
Intrauterine growth restriction
Congenital malformation
Incompetent cervix
Blood group sensitization, neonatal jaundice
Neonatal thrombocytopenia
Hydrops
Inborn errors of metabolism
11. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
Present pregnancy
Vaginal bleeding
Sexually transmitted infections
Multiple gestation
Preeclampsia
Premature rupture of membranes
Short interpregnancy time
Poly-/oligohydramnios
Acute medical or surgical illness
Inadequate prenatal care
Familial or acquired hypercoagulable states
Abnormal fetal ultrasonographic findings
Treatment of infertility
12. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
Labor and delivery
Premature labor (<37 wk)
Postdates pregnancy (≥42 wk)
Fetal distress
Breech presentation
Meconium-stained fluid
Nuchal cord
Cesarean section
Forceps delivery
Apgar score <4 at 1 min
13. FACTORS THAT DEFINE AN
INFANT AS BEING HIGH RISK
Neonate
Birthweight <2,500 or >4,000 g
Birth <37 or ≥42 wk of gestation
Small or large for gestational age
Respiratory distress, cyanosis
Congenital malformation
Pallor, plethora, petechiae
14. MULTIPLE GESTATION
Incidence of spontaneous dizygotic twinning
is highest among blacks and East Indians,
followed by northern European whites, and is
lowest in the Asian races
The incidence of monozygotic twins (3-
5/1,000) is unaffected by racial or familial
factors
Triplets are estimated to occur in 1 in 86
pregnancies and quadruplets in 1 in 86
pregnancies in the United States (Check
Nigerian data)
15. PROBLEMS OF MULTIPLE
GESTATION
Polyhydramnios
Hyperemesis gravidarum
Preeclampsia
Premature rupture of membranes
Vasa previa
Velamentous insertion of the umbilical cord
Abnormal presentations (breech)
Premature labor.
16. PROBLEMS OF MULTIPLE
GESTATION
Obstruction of the circulation secondary to
intertwining of the umbilical cords
Respiratory distress syndrome and asphyxia
(second twin)
Intrauterine growth restriction
Twin–twin transfusion
Congenital anomalies
17. MANAGEMENT
Early detection and anticipation
Quality antenatal care – adequate caloric
and protein intake, haematinics, iron and
folate supplementation, regular visits, fetal
surveillance / monitoring
Prevention of preterm labour
Administration of corticosteroid if preterm
labour is anticipated
Appropriate labour management
Management of prematurity
Management of twin-twin transfusion ( if
present)
18. TWIN-TWIN TRANSFUSION
Is a rare complication that can occur in
monozygotic monochorionic diamniotic
twins, which causes the blood to pass from
one twin to the other
Usually occurs due to the presence of
placental vascular communication
The donor becomes undernourished and
anaemic while the recipient grows normally
and plethoric
Management more of obstetrics, surviving
infants are managed according to
presentation
20. PRETERM INFANTS
Term = 37weeks to 42 weeks
Subdivision by American College of Obstetrics
and Gynecology
Early term = 37weeks + 0day to 38weeks + 6days
Full term = 39weeks + 0day to 40weeks + 6days
Late term = 41weeks + 0day to 41weeks +6days
Preterm = less than 37weeks
extremely preterm (less than 28 weeks)
very preterm (28 to <32 weeks)
moderate to late preterm (32 to <37 weeks) 2,4
21. PRETERM INFANTS
Prematurity is the leading cause of death in
children under the age of 5 years 2
Half of the babies born at or below 32 weeks
(2 months early) die due to a lack of
feasible, cost-effective care, such as
warmth, breastfeeding support, and basic
care for infections and breathing difficulties
22. CAUSES OF PRETERM BIRTH
Idiopathic
Induction of labour
Caesarean section
Multiple pregnancies
Infections
Diabetes mellitus
Hypertensive diseases in pregnancy
Extremes of maternal age
Preterm premature rupture of
membranes
23. CAUSES OF PRETERM BIRTH
Polyhydramnios
Antepartum haemorrhage
Stressful life event
Uterine/cervical
malformations/abnormalities
Cervical trauma
Drug abuse
Recurrent mid-trimester miscarriage
27. MANAGEMENT OF PRETERM
INFANTS
Principles of management 3
Identification of the clinical problem that the
infant is at risk of developing
Prevention of the problem
Identification of problems when they occur
Early treatment of the problems
28. MANAGEMENT OF PRETERM
INFANTS
At delivery
clear the airway
initiate breathing,
care for the umbilical cord and eyes,
administer vitamin K
Subsequent management
thermal control
monitoring of the heart rate and respiration
oxygen therapy (if indicated)
fluid management
nutrition.
Prevention of infection
29. Thermal control
Keep thermoneutral environment – provide
warm environment and humidity
Maintain core temperature at 36.5-37.0°C
Incubators or radiant warmers can be used
Alternatives are: Kangaroo mother care with
direct skin-to-skin contact, a hat and blanket
covering the infant
30. FLUID BALANCE
Very immature preterm infants (<1,000 g) may
lose as much as 2-3 mL/kg/hr
Larger premature infant (2,000-2,500 g) nursed
in an incubator may have an insensible water
loss of approximately 0.6-0.7 mL/kg/hr.
VLBW babies are less able to concentrate urine,
so they need higher fluid intake to excrete
solutes
Adequate fluid intake is essential for excretion
of the urinary solute load (urea, electrolytes,
phosphate).
Start with 70-80 mL/kg on day 1 and advance
gradually to 150 mL/kg/day.
31. TOTAL PARENTERAL NUTRITION
The goal is to deliver sufficient calories from
glucose, protein, and lipids to promote
optimal growth
Indication
before complete enteral feeding has been established
when enteral feeding is impossible for prolonged
periods
Route of administration
percutaneously
surgically placed indwelling central venous catheter
peripheral vein.
umbilical vein ( for up to 2 wk)
32. TOTAL PARENTERAL NUTRITION
The infusate should contain
2.5-3.5 g/dL/day of synthetic amino acids and
10-15 g/dL/day of glucose,
2-3g/kg/day of fat emulsion e.g. intralipid 20%
appropriate quantities of electrolytes, trace
minerals, and vitamins.
The content of each day’s infusate should be
determined after careful assessment of the
infant’s clinical and biochemical status
33. TOTAL PARENTERAL NUTRITION
Complications
Complication from catheter Complication from infusate
metabolism
Infection Hyperglycemia
Thrombosis osmotic diuresis
Extravasation of fluid Dehydration
Accidental dislodgment Azotemia
Phlebitis Nephrocalcinosis
Cutaneous sloughing, Hypoglycemia
Hypoxemia
hyperammonemia
34. ENTERAL FEEDING
Oral feeding (nipple) should not be initiated
or should be discontinued in infants with
respiratory distress
hypoxia
circulatory insufficiency
excessive secretions
gagging
sepsis
central nervous system depression
severe immaturity
signs of serious illness
35. ENTERAL FEEDING
The main principle in feeding premature infants
is to proceed cautiously and gradually.
Careful early feeding of breast milk or formula
tends to reduce the risk of hypoglycemia,
dehydration, and hyperbilirubinemia
Preterm infants at 34 wk of gestation or more
can often be fed by bottle or at the breast.
Direct breastfeeding may not be successful in
very preterm infants due to poor sucking effort,
so baby may need be fed by bottle or tube
36. ENTERAL FEEDING
Trophic feeding is the practice of feeding very
small amounts of enteral nourishment to VLBW
preterm infants to stimulate development of
the immature gastrointestinal tract.
Benefits of trophic feeding include
enhanced gut motility,
improved growth,
decreased need for parenteral nutrition,
fewer episodes of sepsis,
shortened hospital
37. ENTERAL FEEDING
For infants <1 kg, the initial trophic feedings
can be given at 10-20 mL/kg/24 hr as a
continuous nasogastric tube drip (or given by
intermittent gavage every 2-3 hr) for 5-10
days.
If the initial feedings are tolerated, the
volume is increased by 20-30 mL/kg/24 hr to
a maximum of 150ml/kg/24hr
38. ENTERAL FEEDING
For infants weighing >1.5 kg , feeding is
initiated at a volume of 20-30 mL/kg/24 hr
Increase by total daily formula volume of 20-
30 mL/kg/24 hr.
Indication for review/stoppage of feeding
regurgitation,
vomiting,
abdominal distention,
gastric residuals from previous feedings (as
indicated by gastric aspiration)
39. ENTERAL FEEDING
LBW and preterm infants should be given
supplemental vitamins because the volume
of milk sufficient to satisfy daily
requirements may not be ingested for
several weeks
40. PREVENTION OF INFECTION
Prevention strategies include:
strict compliance with handwashing and universal
precautions,
minimizing the risk of catheter contamination and
duration,
meticulous skin care,
encouraging early appropriate advancement of
enteral feeding,
education and feedback to staff,
surveillance of nosocomial infection rates in the
nursery
Prophyalctic antibiotics may be given 5
41. POSTTERM INFANTS
Postterm infants are those born after 42
completed weeks of gestation (from LMP)
regardless of weight at birth.
Cause is unknown, risk factors include
Wrong dates
Maternal factors - primiparity, previous history of
prolonged pregnancy, sedentary habits, genetic
predisposition and elderly multipara.
Fetal factors - Fetal congenital anomalies such as
anencephaly and adrenal hypoplasia; fetal male
sex
Placental factors - sulfatase deficiency
42. POSTTERM INFANTS
Common features of post maturity syndrome
include
Desquamation of the skin / wrinkling
long nails,
abundant hair,
pale skin,
alert faces,
loose skin, especially around the thighs and
buttocks
meconium-stained nails, skin, vernix, umbilical
cord, and placental membranes
44. MANAGEMENT
Careful obstetric monitoring, including
nonstress testing,
Biophysical profile,
Doppler velocimetry
Choosing appropriate mode of delivery less
risky for the baby
nonintervention and subsequent vaginal delivery
induction of labor, or
Cesarean section
Treatment of medical problems in the
newborn if they arise
45. LARGE FOR GESTATIONAL AGE
Are infants with birthweight > the 90th
percentile for gestational age
Predisposing factors include:
Large parental size
maternal diabetes
Obesity
46. LARGE FOR GESTATIONAL AGE
Complications –
cervical and brachial plexus injuries,
phrenic nerve damage with paralysis of the
diaphragm,
fractured clavicles,
cephalohematomas, subdural hematomas, and
ecchymoses of the head and face.
hypoglycemia
polycythemia.
congenital anomalies
47. MANAGEMENT
Antenatal detection of at risk infants
Skilled delivery practices to prevent or
minimize birth injuries
Management of hypoglycemia and metabolic
problems
Management of birth injuries
49. MANAGEMENT
Preconception and frequent prenatal
evaluations of all women with diabetes and
pregnant women with gestational diabetes,
Evaluation of fetal maturity, biophysical
profile, Doppler velocimetry, and planning of
the delivery of these infants in hospitals
where expert obstetric and pediatric care is
continuously available.
50. MANAGEMENT
Check RBS, serum E/U/Cr
Infants should initiate feedings within 1 hr
after birth
A screen glucose test should be performed
within 30 minutes of the first feed
Treatment is indicated if the plasma glucose
is <40 mg/dL and clinical symptoms of
hypoglycemia are present.
In asymptomatic infants, treatment is
indicated if the plasma glucose is <30 mg/dl1
51. MANAGEMENT
A dose of 200 mg/kg of dextrose (2 mL/kg of
10% dextrose) should be administered to
infants with plasma glucose below these
limits.
If baby cannot tolerate orally, a continuous
peripheral intravenous infusion at a rate of
4-8 mg/kg/min should be given
Avoid bolus hypertonic glucose, it may cause
further hyperinsulinemia and rebound
hypoglycaemia
Treat other electrolyte problems accordingly
52. DISCHARGE CRITERIA FOR HIGH
RISK INFANTS
Growth should be occurring at steady
increments of approximately 30 g/day.
Temperature should be stabile in an open crib.
Infants should have had no recent episodes of
apnea or bradycardia
Parents, or alternative caregivers, who are
willing and able to provide all aspects of the
infant’s care
Drugs should be oral
53. DISCHARGE CRITERIA FOR HIGH
RISK INFANTS
Eye test to rule out retinopathy
Hearing test
Check Hb to rule out anaemia
A coordinated plan for outpatient or home
nursing follow-up visits
54. CONCLUSION
High risk infants require special attention
and optimal care to reduce morbidity and
mortality. Therefore adequate antenatal
care, specialized delivery and early referral
for optimal neonatal care will go a long way
in averting the series of problems associated
with them and help prevent both short term
and long term complications.
55. REFERENCES
1. Kliegman, Robert, Richard E. Behrman, and Waldo E.
Nelson. Nelson textbook of pediatrics. 20th edition.
2016.
2. World Health Organization - Preterm birth fact
sheets. Available at
http://www.who.int/mediacentre/factsheets/fs363
/en/
3. Howson CP, Kinney MV, Lawn JE. Born too soon: the
global action report on preterm birth. Geneva:
World Health Organization. 2012 May:1-126
4. Azubuike JC, Nkanginieme KE. Paediatrics and child
health in a tropical region. 2nd edition. African
Educational Services. 2007
56. REFERENCES
5. Saxena R. Bedside Obstetrics & Gynecology. JP
Medical Ltd; 2014
6. Medscape: Infant of diabetic mother. Available at:
https://emedicine.medscape.com/article/974230-
overview#a2
7. Multiple Indicator Cluster Survey. Nigeria Survey
Finding Report, 2016-2017
8. Cunningham F, Leveno K, Bloom S, Hauth J, Rouse D,
Spong C. Williams Obstetrics 23rd Edition McGraw
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