Volume 13, Number 6, November/December 1984

Journal of Obstetra. Gynecdogic. and Neonatal Nursing

Special Considerations in the Nursing Care of the Very Low Birth Weight Infant ANNE MCCOh!MICK, RN, MS

Improvement in obstetric and neonatal care has resulted in an increase in the number of very low birth weight infants (less than 1000 grams) being cared for in neonatal intensive care units. This article addresses issues related to the special nursing implications required in the care of these infants.

Significant improvement in both the mortality and morbidity of the very low birth weight infant has been occurring over the last 10 years.’-4 Many factors have contributed to this improvement, including both technological advances and attitudinal considerations. As the number of these infants being admitted to neonatal intensive care units (NICUs) increases, nurses must be aware of considerations specific to the care of these special patients.

OBSTETRIC CONSIDERATIONS

Aggressive antepartum, intrapartum, and imme- diate newborn care is essential in promoting optimal outcome of these infants. This care is best provided at tertiary-care facilities where comprehensive care is available for both mother and infant. When these facilities are not possible, close collaboration among the various levels of care providers is essential.

When labor inhibition is not indicated or has proven unsuccessful, major emphasis is on the pre- vention of trauma and asphyxia to the fetus. The very low birth weight infant, being less well adapted to the stresses of labor than the larger preterm or full-term infant, is at significant risk for the devel- opment of such complication^.^ Numerous factors

Submitted: March 1983. Accepted with revisions: September 1983.

predispose this infant to trauma and asphyxia. De- creased skull protection increases susceptibility to intracranial hemorrhage. Furthermore, the infant is at risk for hypoxia due to lower hemoglobin concen- tration, which results in a lower oxygen-carrying capacity. Glycogen stores, which provide glucose in response to hypoxia, are limited during this gestational period. Minimal surfactant exists, which can be in- activated by hypoxia. Prevention of hypoxia is para- mount to prevent intraventricular hemorrhage, a major concern for infants in this birth weight category (Table 1).

In approaching intrapartum management, several factors have been identified as obstetric contributors that improve outcome. The two most significant are continuous electronic fetal monitoring and cesarean delivery.

Continuous Fetal Monitoring

The use of electronic fetal monitoring is mandatory for the accurate detection of abnormal heart rate patterns. In studies of very low birth weight infants, abnormal patterns were significantly indicative of actual fetal acidosis; prompt identification followed by immediate intervention decreased the conse- quences of a s p h y ~ i a . ~ . ~

Internal monitoring provides a more accurate as- sessment; however, since the intact amniotic sac serves

November/December 1984 JOGN Nursing 357

Radiant Warmer Table 1. Intraparturn Concerns for the Very Low Birth Weight Fetus

Lower hemoglobin concentration - lower oxygen-carrying

Minimal amounts of surfactant Decreased tolerance to maternal medications Scarce glycogen stores No fat Thin epidermis Decreased skull protection Immaturity of cerebral vasculature - CNS hemorrhage Increased incidence of breech presentation

capacity

Prolapse of the umbilical cord Trapping of the head by the cervix

as a cushion against the cerebral trauma and cord compression that can occur with ruptured membranes, a dilemma in choosing between internal versus exter- nal monitoring does e x i ~ t . ~ . ~

Method of Delivery

A greater percentage of breech presentation occurs with decreased gestational age.' As increased perinatal mortality and morbidity has been associated with breech delivery, cesarean delivery has recently been advocated for the preterm breech to reduce the associated complications of fetal distress, trauma, prolapse of the cord, and trapping of the head by the cervix, which occur in vaginal deliveries. Cesarean deliveries have resulted in lower mortality, decreased incidence of intracranial hemorrhage, and fewer cases of trauma.' With regard to cephalic presentation, controversy remains over the selected method of delivery.

Whatever the method of delivery, a skilled neonatal team must be present at birth to provide immediate care to the infant. Resuscitation measures, under a radiant warmer, must be gentle to prevent trauma. With regard to aggressive management, elective in- tubation at birth has been associated with increased ~urvival .~ After stabilization measures, the infant should be transferred to the NICU without inter- rupting the provision of heat and oxygen.

THERMOREGULATION

Principles of thermoregulation must be adhered to because these tiny patients are at significant risk of hypothermia due to their small body mass, larger surface area, thin skin and minimal subcutaneous tissue, and posture. In the NICU, heat may be provided through the use of the standard incubator or radiant warmer. Both units have advantages and disadvantages that must be considered.

The use of radiant warmers has increased steadily since their introduction. Radiant warmers provide accessibility for the performance of numerous pro- cedures and improved visibility of the high-risk infant, without the interruption of heat. A serious side effect, however, is a significant increase in insensible. water loss (IWL), the loss of water from the lungs and skin through evaporative and convective heat losses. 'OS1

Attempts to reduce the IWL have included the use of plastic sheeting and heat shields. The use of thin plastic blankets has recently been found to be most effective in reducing the IWL; heat shields are not as efficient and may also impede radiant heat transfer and interfere with the bed's servocontrol func- tion. 12-14

Incubators

Incubators have decreased accessibility and visibil- ity. However, they are not associated with an increased IWL. In addition, incubators can provide humidity and isolation. The use of heat shields or double- walled units are effective means of reducing heat loss occurring during entry into the incubator. Another advantage is that the infant can be weighed inside with a sling, with minimal disruption of the environ- ment.

FLUIDS AND ELECTROLYTES

The management of fluids and electrolytes in this population is extremely complex because the physi- ology of fluid homeostasis is essentially unknown. l 4

Factors to be considered include percent of body water, renal function, and replacement of losses, particularly insensible water loss.

Proportion of Body Composition of Water

The body water content is indirectly related to the level of maturity, decreasing with increasing maturity; total body water at 30 weeks gestation is approxi- mately 80%.15 During the first week of life, 10% to 15% of body weight is lost due to contraction of extracellular body fluid and tissue breakdown second- ary to inadequate caloric intake.I6

Renal Function

Adaptation to extrauterine life is especially chal- lenging to the immature kidney of the preterm infant. A lower glomerular filtration rate results in a limited capacity to excrete water and sodium loads. Maximal concentrating ability is limited to 600 to

358 November/December 1984 JOGN Nursing

700 mOSm/kg HZO; therefore, fluid conservation is limited when fluids are restricted. The renal threshold of glucose is much lower, with values approximately

Table 2. Recommendations for Starting Parenteral Fluid Maintenance in Low Birth Weight Newborn Infants'

.. 156 mg/dl," which can cause glycosuria at lower serum glucose concentrations.

Weight (gm) ~

600-800 801 -1 000

Radiant warmer Insensible Water Loss Volume, ml/kg/dayt 120 90

The estimation of fluid requirements is determined Dextrose, O/O 5 10 by the replacement of fluid volume and insensible Saline, O/O$ 0.1 0.2 water loss. Insensible water loss is markedly increased in infants less than 30 weeks g e ~ t a t i o n . ' ~ . ' ~ The calculation of IWL is exceptionally complex, as both environmental and infant factors influence the mag- nitude of the loss.

Factors that increase insensible water loss in the extremely preterm infant are a larger body surface area per kg body weight, greater percentage of body water, and a thinner, more permeable and vascular- ized epidermis. In addition, respiratory distress will increase I WL in spontaneous breathing infant^.'^

Environmental concerns regarding fluid balance include the effects of radiant warmers and photo- therapy units, which are standard in the care of these infants. A number of studies have demonstrated that insensible water loss was far greater in infants cared for in radiant warmers versus the standard incubator, due to evaporative and convective losses from the infant's skin. An increase in IWL also occurs with ph~totherapy. '~ Thus, infants receiving phototherapy while cared for in a radiant warmer have a further increase' in IWL that must be considered in fluid therapy . Initiation of Fluid Therapy

Due to these factors, fluid and electrolyte therapy is cautiously and closely monitored. Thorough assess- ment prevents the dehydration, hypotension, hyper- natremia, poor perfusion, and inadequate calories associated with too severely restricted fluids while simultaneously avoiding the complications of pulmo- nary edema, patent ductus arteriosis, bronchopul- monary dysplasia, and necrotizing entercolitis, which have been related to overhydration in this population.

Recommendations for fluid requirements are de- fined in Table 2. Dextrose concentrations of less than 10% should be considered initially to prevent hyper- glycemia. Sodium recommendations range from 1 to 4 mEq/kg/day, starting on the second or third day of life. Sodium concentrations should be monitored closely due to the infant's limited capacity in excreting sodium. Due to the fact that the administration of sodium bicarbonate affects sodium levels, it must be used cautiously. Potassium is started on the second day at 1 to 2 mEq/kg/day.

Incubator Volume, ml/kg/dayt 90 75 Dextrose, O/O 7.5 10 Saliine, YO$ 0.1 0.2

Volume, ml/kg/dayt 70 55 Dextrose, YO 7.5 10 Saline, O/O$ 0.1 0.2

Either, with shield

Adapted with permission from Baumgart S. et a/. Fluid and electrolyte, and glucose monitoring in the very low birth weight infant. Clin Pediatr 1982; 21 (4): 199-205. t Plus 30% with phototherapy. * After first day of life.

Fluid requirements may vary from infant to infant, so adjustments are made according to assessments accrued through a well-structured monitoring system. Fluids are administered at a constant rate via an infusion pump. Intake, including flushes, and output must be recorded accurately.

Average urine output is 0.5 to 1 ml/kg/hr. Specific gravity is measured with each void. Values less than 1.010 are suggestive of overhydration and fluids should be restricted; values greater than 1.016 are indicative of underhydration. In performing urine evaluation from diaper specimens, freshly voided urine should be used. Delays in checking the diaper for voidings permit urine evaporation, which can result in significant error of measurement, leading to less than optimal calculation of requirements."

Serum sodium and glucose determinations are frequently obtained every 8 to 12 hours; greater than 150 mEq/l is a sign of sodium overload and could indicate water deficit. Glucose levels should be main- tained between 45 and 90 mg/dl. Weights are mea- sured every 12 hours. A trend in weight loss greater than 10% per day indicates underhydration."

Parenteral Alimentation with Amino Acid Solution

Increased survival among preterm infants can be attributed to significant advances in nutritional sup- port, including hyperalimentation. This form of sup- port' is generally initiated during the first week of life when enteral feedings are contraindicated. Peripheral

Novernber/Decernber 1984 JOGN Nursing 359

venous administration with a concentration of glucose not exceeding 12% is the preferred method of choice; central catheters have not been established as a routine safe form of administration and should be reserved for specific indi~ations.2~ The site of admin- istration must be closely observed for infiltration, which can result in severe tissue necrosis. Careful monitoring of blood chemistries will alert the nurse to possible metabolic alterations such as hypergly-

Composition

Selection of the optimal form of enteral nutrition has been difficult due to insufficient knowledge and understanding of the infant's requirements. Individual preferences tend to determine the composition se- lected, whether breast milk or formula.

Breast . . _ .

cemia, hyperammonia, electrolyte imbalance, meta- bolic acidosis, and mineral defi~iencies.'~ Glucose concentrations must be immediately reduced when hyperglycemia occurs; in specific prolonged cases, insulin administration has been re~ommended.'~

To maintain adequate weight gain, which is difficult due to the necessary restriction of fluid volume, intravenous fat emulsion may be added. Initiation of 1 to 1.5 gm/kg/day not to exceed 2 to 3 gm/kg/ day is recommended for a short duration because fat is cleared very slowly from the plasma.16 With cautious administration, potential side effects such as hyperli- pemia, hepatic toxicity, and decreased oxygenation will, hopefully, be avoided. Close monitoring of liver function studies, serum lipids, and blood gases are ne~essary.'~

Initiation of Feedings

Although it has been proposed that optimal growth rate of the very low birth weight infant should approximate normal intrauterine growth, questions have arisen over whether this goal truly addresses the needs of the infant in an extrauterine environ- ment. Thus, controversy results over the best form of oral nutrition.

Unless contraindicated by factors such as severe infection and cardiorespiratory disorders, feedings are initiated by the end of the first week of life. The infant's immaturity, small gastric capacity, and re- duced intestinal motility mandate a cautious approach. A first feeding of 1 cc of sterile water assesses infant tolerance. With no evidence of gastric residual mea- sured several hours later, general feedings may follow, gradually increasing the feeding by 1 to 2 cc to meet caloric requirements. Intravenous therapy is adjusted according to the feeding regimen.

Method

Continuous gastric feedings via infusion pump assist in the absorption of the volume, without taxing the infant's limited gastric capacity, thereby prevent- ing complications associated with intermittent tech- niques. These complications have included vomiting and aspiration and respiratory difficulties from the abdominal distention associated with bolus feedings.

The use of breast milk for premature infants was introduced due to the advantages of immunologic factors, unique composition, and psychologic benefit for the mother. Controversy has arisen over whether breast milk provides adequate requirements for growth,26 contributing to the debate over the best form of nutrition. Recent research, however, indicates that the composition of milk varies from mothers delivered prematurely versus those at term; preterm breast milk may be the best selection due to its higher protein and mineral comp~sition.~'

Fresh mother's milk is always preferred over donor, pooled milk. When donor milk is used, strict adher- ence to principles of collection and storage must be p r a c t i ~ e d . ~ ~ * ' ~

Formula

The new premature formulas have been developed to provide adequate and safe nutrition to the very low birth weight infant. Principle differences from standard formula include a higher concentration of protein in the form of whey, which facilitates diges- tion, decreased amount of lactose with carbohydrate in the form of glucose polymers, resulting in lower osmolarity, and medium-chain triglycerides, which improve fat and calcium absorption. Sodium content has also been adjusted to prevent the hyponatremia common in these infants. The addition of calcium and phosphorous prevents mineral deficits, which have been known to occur in infants fed with breast milk.

Infant tolerance of the feeding schedule must be observed, reported, and documented. Consistent ad- ministration via the infusion pump must be assured. Nursing assessment includes observation for abdom- inal distention, abdominal palpation, measurement of abdominal circumference, and auscultation for bowel sounds. Measurement of gastric residuals is routine; the amount aspirated should never exceed the amount being infused, which would warrant a more conser- vative approach. Stools should be evaluated for num- ber, consistency, and presence of blood, water, or mucous. A Chitest@ result of more than I + may indicate incomplete absorption of sugar. Documen- tation of these assessments is essential and must include

360 November/December 1984 JOCN Nursing

Composition-breast milk (donor or mother) or brand of formula, caloric density, rate of infusion, infusion totals

Method -continuous infusion versus intermittent

Tolerance -(A) abdominal circumference, presence of distention

(B) amount of residual (C) stool-number, description,

Clinitest results, Guiacm test if pertinent

(D) weight gain

Proper positioning in the right lateral or prone position is fundamental to reduce the likelihood of aspiration.

HYPERBILIRUBINEMIA

The management of hyperbilirubinemia in the very low birth weight infant remains a challenge to practitioners due to the inability to establish specific criteria for intervention. These infants have been reported to be at critical risk for bilirubin-related brain damage at serum concentration as low as 6 to 9 mg/d1,30,3' without clinical evidence of kernic- term.'* The prevention of kernicterus is an unsolved problem; no level exists within which to institute intervention, due to the inaccuracy of bilirubin mea- surements, uncertain diagnosis of kernicterus, and the limitation of knowledge of the blood-brain bar- rier."

Observation for the onset of jaundice, although difficult in this population, is clearly a nursing priority, followed by close monitoring of serum concentrations. Phototherapy remains the treatment of choice, al- though an exchange transfusion may be performed for a bilirubin level as low as 12 mg/dl. In some institutions, prophylactic phototherapy may be insti- tuted on all infants less than 1000 grams, particularly when bruising is present.

Nursing care related to phototherapy includes the standard measures, with particular emphasis on eye and skin care. The administration of ophthalmic drops every two hours assists in preventing dryness. The prevention of hyperthermia and close monitoring of intake and output due to the increased require- ments for insensible water loss is especially important with these infants.

PREVENTION OF INFECTION

Strict adherence to principles of infection control is essential because the immunologic system of the preterm infant is deficient. Equipment and care re- lated to the provision of long-term respiratory and

nutritional support along with frequent laboratory tests present additional risks of infection. In one study, three-fourths of occurring infections with these infants were apparently no~ocomia l .~~ Common pre- senting signs of infection that the nurse must be alert to include apnea, lethargy, feeding retention, abdom- inal distention, unexplained hypotension, and persis- tent metabolic acidosis.

In some special care nurseries, all infants weighing less than 1000 grams are placed on reverse isolation which includes incubator care, sterile linen, and glove precautions by staff. Although the practice of steril- izing linen in the neonatal intensive care unit has been q~estioned,~' personnel must be always mindful of the routines of infection control that are easily forgot ten.

SKIN CARE

The skin, as a boundary organ, is subject to chemical, physical, and infectious influence^.'^ A pre- term birth disrupts the protective environment pro- vided by the amniotic fluid during normal fetal development. Meticulous, gentle nursing care must be provided to protect the extremely preterm infant's skin from traumatic and infectious insults.

Tape is necessary for securing various forms of equipment used in the neonatal intensive care unit, but its use can be injurious to the epidermis. The amount is restricted to avoid undue irritation. Pink tape has been found to be less irritating than standard brands. Op-Site@ and Hollihesive@ have also been used successfully to reduce iatrogenic skin problem^.^' All electrodes require careful placement and consis- tent evaluation to minimize their skin irritation.

The preterm infant has increased skin permeabil- ity.38 Topical ointments should be used with extreme caution to avoid hazards of absorption. The applica- tion of antiseptic preparations requires strict attention because marginal skin barriers predispose the infant to burns.3g Diluted BetadineO solutions have been found to reduce skin injury without compromising prevention of infe~tion.~'

Water mattresses provide a gentle surface, but careful positioning is required to ensure airway maintenance.

MINIMAL HANDLING

Excessive handling may predispose the infant to not only skin trauma, but other complications such as organ injury, infections, and temperature instability. An additional serious concern is hypoxemia. In an evaluation of the effects of handling, T,POp values were found to drop more than 20 mm Hg, with 75% of occurring hypoxemia associated with handling by neonatal intensive care unit personnel.41 Nursing

November/December 1984 JOGN Nursing 361

care, when well organized, can prevent these compli- cations caused by unnecessary frequent and rough handling.

Infant stimulation programs are an important com- ponent of neonatal care. Such programs are best reserved for stable, growing preterm infants. The priority for the very low birth weight infant is pro- tection from overstimulation present in the hostile neonatal intensive care unit environment.

PARENTAL SUPPORT

The literature has frequently addressed the special needs of parents of high-risk infants; working with parents of infants less than 1000 grams requires comprehensive understanding and application of these principles. Supporting parents of the tiny premature is additionally difficult and stressful due to the many unknown factors inherent in the care involved. Es- sential is the establishment of an open, honest rela- tionship initiated upon the infant’s admission. Due to the numerous caretakers in neonatal units, a primary nurse and physician can coordinate all information shared with the parents to eliminate the possibility of conflicting reports. The nurse must communicate information consistently, with necessary reinforcement excluding unrealistic expectations.

Referral to additional resources such as parent support groups, chaplain, and social services and psychology are offered and arranged as the need is assessed. The individuality of each parent must be respected, however, for not all persons desire partic- ular services. Available resources can be identified and facilitated, but the decision to participate is dependent upon parental choice.

DISCHARGE PLANNING AND FOLLOW-UP

Discharge planning commences upon admission to the neonatal intensive care unit, for even early inter- actions will impact the future development of the family unit. The incorporation of discharge planning theories must be as high a priority to the neonatal intensive care unit nurse as proficiency in technical skills. Parental support and education are best pro- vided by specific key personnel. Primary nursing assists the family members in developing a positive relationship that will lead to optimal outcome through consistent communication of infant status and care.

As outcome of the low birth weight infant is being closely evaluated at all perinatal centers, follow-up programs are a high priority. Follow-up personnel can be introduced during the hospitalization period to acquaint the family with future care perspectives. Communication between the primary nurse and fol- low-up nurse will facilitate the meeting and under- standing of individual family needs.

Community resources are identified to provide the family with appropriate assistance at home. In the state of Illinois, all high-risk infants are referred to local community agencies u p n discharge. Open COl-

laboration among nurses from tertiarycare units and community agencies provides families with the corn- prehensive care essential after discharge.

SUMMARY

The extremely preterm infant thus presents the neonatal intensive care unit nurse with a most complex challenge. From admission through discharge and follow-up, the unique needs of the infant and family must be given most careful consideration. Outcome is surely determined by the specific nursing care delivered to these patients and their families.

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Address for correspondence: Anne McCormick, RN, 6723 Lockwood, Lincolnwood, IL 60646.

Anne McCormick is an independent perinatal nursing consultant. S h e is a member of NAACOG, ANA Council of High Risk Perinatal Nurses, and NPA.

November/December 1984 JOGN Nursing 363