What are the potential issues for a premature or critically ill newborn in the Neonatal Intensive Care Unit (NICU) with a limited medical history and possible underlying conditions related to prematurity or congenital anomalies?

Potential Issues for Premature or Critically Ill Newborns in the NICU

A NICU nurse must anticipate and monitor for multiple life-threatening complications that commonly affect premature and critically ill newborns, with respiratory distress, infection, metabolic instability, and congenital anomalies representing the highest priority concerns.

Respiratory Complications

Respiratory distress syndrome (RDS) is the most common respiratory issue requiring immediate escalation of support, starting with supplemental oxygen or CPAP, with preparation for surfactant administration if oxygen requirements exceed 30-40% FiO₂ on CPAP 1.

• Premature infants with surfactant deficiency require prophylactic or early rescue surfactant (within 2 hours of birth) to reduce mortality by 47% 1
• Delayed surfactant administration increases risk of pneumothorax, pulmonary interstitial emphysema, and death 1
• Persistent pulmonary hypertension of the newborn (PPHN) presents with severe, refractory hypoxemia and labile oxygen saturations, often as a secondary complication 1
• Bronchopulmonary dysplasia (BPD) occurs in 26% of very low birth weight (VLBW) infants and requires prolonged oxygen therapy 2
• Premature or low birth weight infants with bronchopulmonary dysplasia merit special attention as they are at risk to develop severe illness requiring ICU admission 3

Oxygen Management Considerations

• Maintain SpO₂ above 90% in most cases, but consider maintaining higher SpO₂ in children with fever, acidosis, or hemoglobinopathies that shift the oxyhemoglobin dissociation curve 3
• Oxygen-dependent infants with peripheral avascular retina remain at risk for retinopathy of prematurity (ROP) progression; administer oxygen with care and monitoring to avoid sustained hyperoxemia 3
• Stage 3 or higher ROP occurs in 11% of VLBW infants 2

Infectious Complications

Infection represents the most common cause of diagnostic error and mortality in both PICU and NICU settings, with 62% of class I (potentially lethal) misdiagnoses in the NICU being infection-related 4.

• Nosocomial infection occurs in 22% of VLBW infants despite 75% receiving antibiotics in the NICU 2
• Confirmed intrauterine SARS-CoV-2 infections occurred in multiple cases with early cord clamping, presenting with hypoxia, oxygen therapy, CPAP, intubation, and bacterial co-infection 3
• Sepsis requires exclusion when evaluating for sudden unexpected postnatal collapse (SUPC) 3
• 7% of all NICU patients experience at least one episode of infection 2

Neurological Complications

Hypoxic-ischemic encephalopathy (HIE) with therapeutic hypothermia represents critical neurologic injury requiring extended monitoring and phenobarbital therapy, with significant impact on neurodevelopmental outcomes 5.

• Grade 3 or higher intraventricular hemorrhage (IVH) occurs in 10% of VLBW infants 2
• White matter injury can occur following asphyxia and neurological compromise, particularly in infants with confirmed intrauterine infections 3
• The combination of HIE and meconium aspiration syndrome creates high risk for persistent pulmonary hypertension, occurring in 22% of HIE patients and 39% of those with concurrent meconium aspiration 5

Gastrointestinal and Nutritional Issues

Feeding difficulties are common in late preterm/term infants post-HIE and require close surveillance 5.

• Necrotizing enterocolitis (NEC) occurs in 7% of VLBW infants and requires standardized feeding protocols with careful advancement based on tolerance 6, 2
• Term infants with intrauterine growth restriction (IUGR) and risk factors for NEC require continuous cardiorespiratory monitoring, careful feeding protocols with slow advancement, and regular abdominal examinations 6
• Adequate caloric intake is critical to allow pulmonary maturation and somatic growth in infants with chronic lung disease 3
• Enteroraghia requiring blood transfusion can occur in premature infants with atelectasis 3

Metabolic Complications

Critical metabolic monitoring is mandatory, including glucose monitoring and maintaining blood glucose between 90-180 mg/dL during the transition period to prevent hypoglycemia and subsequent neurological injury 1.

• Maternal diabetes compounds the risk of RDS through delayed fetal lung maturation, as maternal hyperglycemia inhibits surfactant production 1
• Hypocalcemia can present with symptomatic sinus bradycardia 3
• Hyperbilirubinemia requiring phototherapy occurs commonly and may contribute to vulnerable child syndrome 3
• Inborn errors of metabolism including aminoacid disorders, urea cycle anomalies, and organic acidemias require consideration 3

Congenital Anomalies

Congenital anomalies account for 10% of NICU admissions but are responsible for 26% of total NICU mortality, 32% of all deaths within the first year, and 35% of all NICU infants with IUGR 7.

• The highest mortality is associated with multiple abnormal prenatal ultrasound findings, extreme prematurity (<30 weeks gestation), and presence of IUGR 7
• Preterm infants are more likely to be born with congenital anomalies than full-term infants, and the comorbid impact is more than cumulative 8
• Congenital heart disease in premature infants shows colinear relationship between degree of prematurity and outcome in terms of both mortality and neurological morbidity 8
• Congenital anomalies of coagulation and acute congenital immunodeficiency syndromes require evaluation 3

Cardiovascular Complications

Assessment of cardiac function using noninvasive hemodynamic monitoring is essential for detecting early deterioration 3.

• Symptomatic sinus bradycardia associated with metabolic disturbances requires monitoring 3
• Truncus arteriosus typically presents with murmur and signs of congestive heart failure rather than isolated respiratory distress at birth 1

Prematurity-Specific Complications

Only 69% of VLBW infants survive without major morbidity (≥grade 3 IVH, chronic lung disease, NEC, ≥grade 3 ROP) 2.

• No infant <22 weeks gestational age survived in the Canadian NICU network study 2
• Chronic lung disease occurs in 26% of VLBW infants 2
• Small for gestational age (<3rd percentile) occurs in 4% of admissions and correlates with increased mortality 2

Psychosocial and Developmental Concerns

Prolonged NICU hospitalization creates vulnerability and dependency on medical personnel and technology, potentially leading to vulnerable child syndrome with long-term implications 3.

• Prevention measures include keeping parents informed, encouraging expression of concerns, supporting appropriate perspectives, and avoiding diagnostic terms without evidence 3
• Fewer family visits during NICU stay correlate with subsequent documented maltreatment 3
• Maternal factors including lower educational level, lack of social support, marital instability, and fewer prenatal care visits increase risk 3
• Parental substance abuse places infants at risk for attachment disturbances, behavioral and developmental disorders, and child maltreatment 3

Medication Safety and Dosing Issues

Altered pharmacokinetics in patients with extensive burns or critical illness may result in reduced serum concentrations of aminoglycosides, requiring measurement of serum concentrations as basis for dosage adjustment 9.

• Premature or full-term neonates one week of age or less require gentamicin 5 mg/kg/day (2.5 mg/kg every 12 hours) 9
• Peak gentamicin concentrations should be 4-6 mcg/mL, with prolonged levels above 12 mcg/mL avoided 9
• Trough gentamicin concentrations should be adjusted so levels above 2 mcg/mL are avoided 9

Environmental and Safety Concerns

The unique aspects and complexity of the NICU environment, combined with vulnerability of the neonatal population, increase risk for medical errors affecting 1 in 10 patients worldwide 10.

• Sudden unexpected postnatal collapse (SUPC) is rare but potentially fatal, with incidence estimated at 2.6 to 133 cases per 100,000 newborns 3
• 73% of SUPC events occur in the first 2 hours of life, with 15 of 26 cases occurring during skin-to-skin care in prone position 3
• Frequent and repetitive assessments including observation of breathing, activity, color, tone, and position may avert positions that obstruct breathing 3
• Continuous staff observation with frequent recording of neonatal vital signs is prudent in the first few hours of life 3

Discharge Planning Considerations

Essential discharge criteria include physiologically stable infant, family capable of providing necessary care with appropriate support services, and primary care physician prepared to assume responsibility 3.

• Discharge planning must consider behavioral implications, feeding, sleep-wake cycles, and home environment preparation, requiring time for parent education and assessment 5
• Mean duration of NICU stay is 19 days, with 47% discharged directly home and 43% retrotransferred to community facility 2
• High-risk infants should receive primary medical care from physician with NICU expertise, often in partnership with specialized clinics 3