HIGH-RISK NEWBORN
High-risk newborn is defined as quot;a newborn with abnormal maternal, antenatal, peripartum or neonatal indicators, suggestive of higher than the normal risk of morbidity and mortality, who should be under close observation by experienced pediatrician and nursesquot;.
About 10% of all live births fall in this category, which need to be either delivered in a hospital set-up or immediately transferred to intensive care unit.
Indicators: A high-risk newborn may be identified at birth due to: (a) high-risk pregnancy, (b) high-risk delivery or (c) postnatal characteristics, e.g. abnormal gestation, birth weight, congenital malformation, etc. Other newborns are added to this category, when exhibit any warning signals in later neonatal period (Table 12.14). Care of a high-risk newborn depends on the time when the risk is identified and the expected severity of complications. While specific measures are discussed in later chapters, important management strategies include:
• Early identification of high-risk pregnancy during antenatal visits, referral to a suitable neonatal care center and if possible, intrauterine interventions.
• Comprehensive review of case-records before delivery for resuscitation alert and adequate resuscitation facility/expertise at the time of delivery.
• Assessment of delivered newborn for high-risk status or warning signals and timely transfer to appropriate neonatal care center.
TABLE 12.14: High-risk neonate
• History of high-risk pregnancy (Table 12.2)
• History of high-risk delivery (Table 12.7)
• High-risk neonatal factors at birth
- PrematurityZpostmaturity
- Small for date/large for date
- Major congenital malformations
• Presence of warning (Danger) signals
- Sluggish activity or cry
- Inability/refusal to accept feeds
- Hypo/hyperthermia
- Respiratory distress
- Vacant stare, seizures or jitteriness
- Not passed urine within 24 hours
- Not passed meconium within 48 hours
- Appearance of icterus lt;24 hours
- Persistent vomiting, choking or frothing
- Abnormal bleeding
Levels of neonatal care: According to the facilities and expertise, neonatal care centers are classified into three levels (tiers):
Level I care is the minimal care level, that should be available to all normal term newborns with birth weight gt;2000 gm.
It may be provided at home or peripheral health center with minimum facilities and includes:• Basic antenatal care, including identification of high- risk pregnancies.
• Delivery, by traditional birth attendant, using safe delivery practices. Basic delivery kit, supplied to these workers under MCH programs include—a sterile blade, clean thread, cotton gauze and an antiseptic soap.
• Essential neonatal care including—(a) proper temperature maintenance, (b) promotion of breastfeeding, and (c) maintenance of adequate asepsis and infection control measures.
• Timely referral to higher center.
In National Heath Mission (India Newborn action plan), each birthing facility must have as Newborn care corner (NBCC) for level I care, to identify and refer at risk or sick babies to higher centers.
Level II care is required in 15-20% newborns with: (a) birth weight 1500-2000 gm, (b) gestation 32-36 weeks,
(c) referrals from level I care, and (d) neonatal problems, e.g. mild/moderate birth asphyxia, Rh incompatibility, common malformations, respiratory distress and maternal diabetes.
It requires pediatrician's supervision and continuous nursing care but not the extensive investigations and intensive care. It should be available at all district hospitals, major and teaching hospitals and nursing homes, dealing with more than 1000-1500 deliveries annually. Important components of level II care include:
• Delivery attended by a trained pediatrician, with adequate resuscitation facility,
• Neonatal care by trained nursing staff, under a pediatrician's supervision
• Facility to provide warmer care, phototherapy, IV infusions/drugs, etc.
In National Heath Mission (India Newborn action plan), each first referral units, e.g. community health centers, must have Newborn stabilization units (NBSU) at block level and Special newborn care unit (SNCU) at district levels.
Level III care is needed in ~ 5% newborns, mainly with—(a) birth weight lt; 1500 gm, (b) gestation lt;32 weeks, (c) referrals from level II care, and (d) serious neonatal complications, e.g.
severe birth asphyxia, major congenital malformations, severe respiratory distress, etc. NICUs should be available at select regional centers or in hospitals with gt;3000 deliveries per year, with following facilities:• Round the clock availability of pediatrician/ neonatologist and trained nursing staff.
• Round the clock availability of allied facilities, e.g. pediatric surgeons, blood bank and pathological/ radiological investigations.
• Advance diagnostic, monitoring and therapeutic facilities, e.g. blood gas monitoring, drug delivery systems (infusion pumps) and procedures, e.g. exchange transfusion, peritoneal dialysis and total parenteral nutrition.
In National Heath Mission (India Newborn action plan), each district hospital or major centers must have Special Newborn Care units (SNCUs) or Neonatal intensive care units (NICUs), in addition to NBCC and NBSU.
Humanized neonatal care: In the current neonatal intensive care environment, a preterm or sick baby is subjected to many non-intentional noxious stimuli, which are believed to have adverse effects on his/ her physiological stability and maturity. Humanized intensive care is not an alternative to high-tech care but is complimentary, to provide holistic care with a human touch, in a baby-friendly womb-like ambience in NICU. Important components of this concept include:
• Minimum noise levels in NICU (leads to startle, apnea, HR/BP fluctuations)
• Minimum light exposure without compromising visual monitoring (excessive light exposure alters circadian rhythm and REM sleep).
• Prone/side-nursing positioning
• Minimum handling
• Breast or expressed breastfeeding
• Allowing the mothers in nursery.
• Gentle tactile stimulation/cuddling (touch therapy)
• Stimulation of special senses, e.g. auditory (soft music), visual (bright colored objects or maternal faces), olfactory (placement of cotton swabs soaked with mother milk in incubators).
Mother-neonatal intensive care unit (M-NICU) is novel concept in humanized neonatal care, where mother is permitted to stay next to the baby in NICU and is encouraged to participate in his/her care after some training, including Kangaroo mother care.
12.9