Part 1 book “Neonatal nursing care handbook” has contents: Systems assessment and management of disorders, respiratory system, cardiovascular system, neurologic system, gastrointestinal system, renal system, hematologic and immune system, surgical care for the neonate,… and other contents.
Neonatal Nursing Care Handbook Carole Kenner, PhD, NNP, RN, FAAN, is internationally known for her work in neonatal nursing, nursing education, and health p olicy establishing the rights of the neonate, standards for n eonatal nursing care and neonatal nursing education, and the reduction of infant mortality worldwide Dr Kenner is the Carol Kuser Loser dean/professor in the School of Nursing, Health, and Exercise Science at the College of New Jersey, Ewing, New Jersey, and the chief executive o fficer for the Council of International Neonatal Nurses, Inc., Yardley, Pennsylvania She has published more than 100 peer-reviewed journal articles, 30 books, and nearly 100 book chapters Dr Kenner has participated as principle investigator, co-investigator, or consultant on approximately 65 research/education/policy grants She is a member of four honorary societies, including the American Academy of Nursing (AAN) (elected in 1994), and is a member of numerous review panels, editorial boards, and consultant groups In 2010, Dr Kenner received the prestigious Audrey Hepburn Award for Contributions to the Health and Welfare of Children from Sigma Theta Tau International In 2014, she received a Lifetime Achievement Award for her work in neonatal nursing from the National Association of Neonatal Nurses (NANN) Judy Wright Lott, PhD, NNP-BC, RN, FAAN, served as the founding dean of the nursing program at Wesleyan College in Macon, Georgia, until 2014 She served as dean, Baylor University Louise Harrington School of Nursing in Dallas, Texas, from 2002 to 2012 Dr Lott has served as a neonatal nurse practitioner (NNP) from 2004 to 2005, associate professor of nursing and director of the NNP Specialty at the University of Cincinnati College of N ursing from 1996 to 2002, and assistant professor, Neonatal Graduate Specialty University of Florida College of N ursing from 1986 to 1990 She has worked in the clinical setting in various capacities since 1976 Dr Lott was inducted into the American Academy of Nursing (AAN) in 2003, joined the American cademic Association of Colleges of Nursing (AACN) Fuld Leadership for A Nursing Program in 2003, and was named visiting professor for the Perinatal Society of Australia and New Zealand (2001) Dr Lott has coauthored four editions of Comprehensive Neonatal Nursing Care with Dr. Kenner Dr Lott has been invited to deliver more than 60 presentations at national and international professional meetings and 17 research presentations She has published more than 20 peer-reviewed journal articles and 35 book chapters, and has been awarded six funded research grants, including a grant from the National Institute of Nursing Research (NINR) Neonatal Nursing Care Handbook An Evidence-Based Approach to Conditions and Procedures Second Edition Carole Kenner, PhD, NNP, RN, FAAN Judy Wright Lott, PhD, NNP-BC, RN, FAAN Copyright © 2016 Springer Publishing Company, LLC All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the Web at www.copyright.com Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Elizabeth Nieginski Composition: diacriTech ISBN: 978-0-8261-7164-1 e-book ISBN: 978-0-8261-7165-8 16 17 18 / The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication Because medical science is continually advancing, our knowledge base continues to expand Therefore, as new information becomes available, changes in procedures become necessary We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Library of Congress Cataloging-in-Publication Data Names: Kenner, Carole, editor | Lott, Judy Wright, 1953-, editor Title: Neonatal nursing care handbook : an evidence-based approach to conditions and procedures / [edited by] Carole Kenner, Judy Wright Lott Other titles: Neonatal nursing handbook Description: Second edition | New York, NY : Springer Publishing Company, LLC, [2016] | Preceded by Neonatal nursing handbook / [edited by] Carole Kenner, Judy Wright Lott c2004 | Includes bibliographical references and index Identifiers: LCCN 2016013689| ISBN 9780826171641 | ISBN 9780826171658 (e-book) Subjects: | MESH: Neonatal Nursing—methods | Evidence-Based Nursing—methods | Handbooks Classification: LCC RJ253 | NLM WY 49 | DDC 618.92/01—dc23 LC record available at http://lccn.loc.gov/2016013689 Special discounts on bulk quantities of our books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups If you are interested in a custom book, including chapters from more than one of our titles, we can provide that service as well For details, please contact: Special Sales Department, Springer Publishing Company, LLC 11 West 42nd Street, 15th Floor, New York, NY 10036-8002 Phone: 877-687-7476 or 212-431-4370; Fax: 212-941-7842 E-mail: sales@springerpub.com Printed in the United States of America by R.R Donnelley Contents Contributors xv Foreword Shahirose Sadrudin Premji, PhD, BSc, BScN, MScN, RN xix Preface xxi Acknowledgments xxiii Share Neonatal Nursing Care Handbook: An Evidence-Based Approach to Conditions and Procedures, Second Edition Section I: Systems Assessment and Management of Disorders Respiratory System Katherine M Newnam Overview Respiratory Distress Syndrome 10 Transient Tachypnea of the Newborn 15 Apnea and Apena of Prematurity 19 Air Leak Syndrome 24 Meconium Aspiration Syndrome 28 Pneumonia 31 Persistent Pulmonary Hypertension of the Newborn 35 Congenital Airway Defects 41 Pulmonary Hypoplasia 41 Pulmonary Hemorrhage 44 Congenital Anomalies That Affect the Respiratory System 45 Congenital Diaphragmatic Hernia 45 Choanal Atresia 47 Pierre Robin Sequence 49 Congenital Pulmonary Malformations 52 Congenital Pulmonary Airway Malformation 52 vi ■ Contents Cardiovascular System 55 Samual L Mooneyham Overview 55 Atrial Septal Defect 60 Samual L Mooneyham Ventricular Septal Defect 64 Samual L Mooneyham Patent Ductus Arteriosus 67 Judy Wright Lott Tetralogy of Fallot 70 Samual L Mooneyham Coarctation of the Aorta 74 Samual L Mooneyham Neurologic System 83 Georgia R Ditzenberger, Susan T Blackburn, Beth Brown, and Leslie B Altimier Overview 83 Central Nervous System Development 86 Neurologic Assessment 89 Neural Tube Defects 95 Disorders of Primary Neurulation 97 Anencephaly 97 Encephalocele 100 Spina Bifida 102 Disorders of Proencephalic Development 107 Holoprosencephaly 108 Holotelencephaly 109 Congenital Hydrocephalus 110 Disorders of Neuronal Proliferation 112 Micrencephaly 112 Macrencephaly 114 Disorders of Neuronal Migration 118 Neonatal Seizures 118 Brain Injury in Preterm Infants 125 Germinal Matrix-Intraventricular Hemorrhage 126 White Matter Injury in Preterm Infants 133 Contents ■ vii Brain Injury in Term Infants 138 Hypoxic–Ischemic Encephalopathy 138 Birth Injuries 148 Extracranial Hemorrhage 148 Intracranial Hemorrhage 152 Primary Subarachnoid Hemorrhage 152 Subdural Hemorrhage 154 Perinatal Stroke 156 Spinal Cord Injury 159 Peripheral Nerve Injuries 161 Radial Nerve Injury 161 Median and Sciatic Nerve Injuries 161 Facial Nerve Palsy 162 Phrenic Nerve Palsy 163 Brachial Plexus Injury 164 Gastrointestinal System 173 Ann Gibbons Phalen Overview 173 Anatomy and Physiology of the Gastrointestinal System 173 Assessment of the Gi Tract 179 Diagnostic Procedures for Evaluation of the Gi Tract 183 Common Nursing Management Interventions Related to GI System Alterations 187 Selected Gastrointestinal Problems in the Neonate 191 Cleft Lip and Palate 191 Gastroesophageal Reflux and Gastroesophageal Reflux Disease 194 Renal System 201 Leslie A Parker Overview 201 Anatomy and Physiology 201 Urinary Tract Infection 202 Acute Renal Failure 205 Hydronephrosis 209 Hematologic and Immune System 215 Carole Kenner Overview 215 viii ■ Contents Blood Group Incompatibilities 215 ABO Incompatibility 216 Rh Incompatibility 217 Erythroblastosis Fetalis 218 Bilirubin 220 Ann Schwoebel Neonatal Infection 227 Tamara Wallace Omphalitis 234 Fungal Infections 234 Congenital Infections 235 Human Immunodeficiency Virus 236 Emerging Threats 243 Section II: Special Care Considerations in Neonatal Nursing 7 Nutrition 249 Breastfeeding 249 Ruth Lucas and Carrie-Ellen Briere Overview 249 Oral Feedings 256 Ksenia Zukowsky Overview 256 Premature Neonates 257 Parenteral Nutrition 261 Surgical Care for the Neonate 267 Michele DeGrazia Overview 267 General Considerations in the Management of the Surgical Neonate 267 Denise Casey and Donna Armstrong Overview 267 Consent 268 Family-Centered Care 269 Fluid and Electrolyte Management 271 Pain Management 277 Surgical Drains, Tubes, Lines, and Airway 283 Contents ■ ix Caitlin Bradley and Melissa Roberts Abdominal Drains 283 Central Venous Lines 285 Chest Tubes 292 Gastrostomy Tubes 297 Gastro-Jejunal Tubes 305 Tracheostomy 313 Surgical Disorders of the Brain and Spinal Canal 321 Eileen C Dewitt and Noel Dwyer Hydrocephalus 321 Myelomeningocele 326 Tethered Cord 329 Surgical Disorders of the Bronchopulmonary Tree and Diaphragm 332 Maura Heckmann and Mary-Jeanne Manning Bronchopulmonary Sequestration 332 Congenital Diaphragmatic Hernia in the Neonate 334 Congenital Pulmonary Airway Malformation 338 Surgical Disorders of the Trachea and Esophagus 344 Patricia Fleck and Monica A Carleton Esophageal Atresia 344 EA with Tracheoesophageal Fistula 347 Tracheoesophageal Fistula (Isolated) 353 Gastrointestinal Surgical Conditions in the Neonate 357 Julie Briere and Michelle LaBrecque GI Surgery General Considerations 357 Duodenal Atresia 359 Gastroschisis 361 Hirschsprung Disease 364 Imperforate Anus 367 Intestinal Atresia 369 Malrotation/Volvulus 371 Meconium Ileus 373 Meconium Plug Syndrome 375 Necrotizing Enterocolitis 377 Omphalocele 381 Surgical Disorders of the Lower Abdomen and Genitals 386 252 ■ II: Special Care Considerations in Neonatal Nursing p0105 ■■ Education and participatory guidance on “triple feeding” during the transition (direct breastfeeding followed by pumping and bottle feeding); consider the recommendations of Meier, Patel, Wright, and Engstrom (2013) p0110 ■■ Consistent breastfeeding follow-up and support at home ti0050 BREASTFEEDING AND DRUGS p0115 Most drugs are approved for lactation and specific guidelines can be found in the book series Medications and Mother’s Milk However, there are certain drugs or medications that may be contraindicated for breastfeeding The characteristics for a safe drug for lactation include a short half-life with no active metabolites, high protein binding, high molecular weight (large molecules), low pH, low oral bioavailability, having a milk-to-plasma (M/P) ratio more than 1, and relative infant dose (RID) that is less than 10% of the maternal dose A greater number of maternal medication is present in colostrum than in mature milk because of the immature mammillary cells However, the small volume of colostrum limits infants’ risk (Casey, 2012) ti0055 Terms to understand about breastfeeding and drugs p0120 ■■ M/P Ratio: The M/P ratio compares the peak concentration of the maternal drug in milk to the peak drug concentration in maternal plasma A ratio of indicates the drug is equally distributed An M/P ratio less than indicates a drug that is less distributed to the breast milk, while more than demonstrates accumulation of the drug in breast milk p0125 ■■ RID: Drug doses are calculated on a per kilogram (kg) basis: a 500-mg drug dose given to a 50-kg woman results in a relative dose of 10 mg/kg An infant weighing kg given the same dose directly would be receiving 100 mg/kg A theoretical guide for infant safety is if the infant’s weight-adjusted dose is 10% of the maternal dose Preterm infants may receive high doses of maternal drug due to their low body weight and immature liver function (see Table 7.1) 7: Nutrition ■ 253 t0005 p0130 TABLE 7.1 Medication Pregnancy Fetal Risk and Lactation Infant Risk Categories Lactation Risk Categories p0135 L1 Designation Description Examples Safest Acetaminophena Ampicillina Amoxicillina Cefazolina Domperidonee Famotidinea Heparina Insulina Ibuprofena Vitaminsa adverse effects ■ Controlled studies fail to demonstrate a risk ■ Possibility of harm is remote ■ Not orally bioavailable to the infant p0140 p0145 p0150 p0155 L2 ■ No observed Safe-limited studies ■ Safety studied Caffeinef with limited Carbamazepineg breastfeeders Citalopramg without adverse Fluoxetineg effects Fluvoxamineg Gentamicina Interferona Meperidineh Metoclopramidee Nicotinef Propranolola Sertralineg St John’s wortd Valproic acidg (continued) 254 ■ II: Special Care Considerations in Neonatal Nursing p0355 TABLE 7.1 Medication Pregnancy Fetal Risk and Lactation Infant Risk Categories (continued) Lactation Risk Categories p0160 L3 Designation Description Moderately safe ■ No controlled Possibly hazardous ■ Evidence of risk Black cohoshd p0165 p0170 L4 p0175 Examples Alcoholf studies in Amphetaminesb breastfeeders Aspirinh ■ Possible risks Benzodiazepinesb should be Buprenorphinec given only if Chamomiled potential Diazepamg benefit justifies Codeineh the potential Echinancead risk to the Fenugreekd,e infant Ginkgod Ginsengd Lamotrigineg Lithiumg Lorazepamb Methadonec Metoprolola Morphineh Naproxenh Oxycodoneh Pseudoephedrinef Valeriand to infant or to breast-milk production ■ Benefits to mothers may be acceptable despite the risk to the infant D2 antagonisti Thioridazinei Thorazinei Radiophar maceuticalsb (continued) 7: Nutrition ■ 255 p0360 TABLE 7.1 Medication Pregnancy Fetal Risk and Lactation Infant Risk Categories (continued) Lactation Risk Categories p0180 L5 Designation Description Examples Contra indicated Blue cohoshd Cannabisb Chemotherapyb Cocaineb Doxeping Heroinb Kavad Metham phetaminesb Methylenedioxymethamphetamine (ecstasy)b Phencyclidine (PCP)b Yohimbed p0185 p0195 p0200 p0190 p0205 p0215 p0210 p0230 p0225 p0220 ■ Significant documented risk or high risk of causing significant damage to the infant ■ If another medication in the drug class will treat the mother effectively and allow the mother to breastfeed, a medication treatment plan needs to be discussed by the maternal and infant caregiver team Notes: a, approved by AAP; b, not recommended by AAP; c, less infant withdrawal symptoms with Buprenorphine; d, not recommended by AAP due to lack of studies; e, galactagogues; f, council mothers to decrease drug intake; g, SSRIs; h, morphine preferred maternal narcotic; i, antipsychotics p0235 Source: D’Apolito (2013) 256 ■ II: Special Care Considerations in Neonatal Nursing ti0065 REFERENCES Adamkin, D H., & Radmacher, P G (2014) Fortification of human milk in very low birth weight infants (VLBW < 1500 g birth weight) Clinical Perina tology, 41(2), 405–421 doi:10.1016/j.clp.2014.02.010 American Academy of Pediatrics (2012) Breastfeeding and the use of human milk Pediatrics, 129(3), e827–e841 Anderson, S M., Rudolph, M C., McManaman, J L., & Neville, M C (2007) Key stages in mammary gland development Secretory activation in the mammary gland: It’s not just about milk protein synthesis! Breast Cancer Research, 9(1), 204 doi:10.1186/bcr1653 Buckley, K M., & Charles, G E (2006) Benefits and challenges of t ransitioning preterm infants to at-breast feedings International Breastfeeding Journal, 1, 13 Casey, G (2012) Breastfeeding and drugs Kai Tiaki Nursing New Zealand, 18(2), 20–24 D’Apolito, D (2013) Breastfeeding and substance abuse Clinical Obstetrics and Gynecology, 56(1), 202–211 Meier, P., Patel, A L., Wright, K., & Engstrom, J L (2013) Management of breastfeeding during and after the maternity hospitalization for late preterm infants Clinical Perinatology, 40(4), 689–705 doi:10.1016/j.clp.2013.07.014 ti0070 Oral Feedings p0240 Ksenia Zukowsky ti0075 Overview p0245 Human breast milk is the recommended food of choice for all infants—term and preterm—rather than formula and other substances Research has demonstrated that infants have better outcomes in the areas of development, immunology, infectious disease, and childhood obesity when fed human milk Additionally, there are also better maternal outcomes noted for mothers who feed their infants human milk (AAP, 2005, 2012) p0250 The enteral caloric recommendations for healthy newborn infants vary according to sources Recommendations may range from 98 to 120 kcal/kg/day for adequate growth and development 7: Nutrition ■ 257 (American Academy of Pediatrics Committee on Nutrition, 1985; Merves, 2012) Enteral caloric recommendations for premature infants are a little higher—110 to 135 kcal/kg/day for growth (Agostoni et al., 2010) These enteral nutrition recommendations are based on the goal of duplicating the rates of intrauterine accretion of the fetus (Pointdexter & Schanler, 2012) The goal of nutritional intake for this population is for the premature infant to grow in extrauterine life at the same rate and composition as the fetus of the same gestational age This extrauterine goal poses a challenge to attain for the premature low-birth-weight infant ti0080 PREMATURE NEONATES p0255 Premature low-birth-weight neonates generally have one or more comorbidities to contend with that may compromise their growth These may include one or more diseases such as bronchopulmonary dysplasia, severe intraventricular hemorrhage, necrotizing enterocolitis, or sepsis, which may contribute to additional demands for the premature infant’s ability to grow (Pointdexter & Schanler, 2012) Preterm infants also have limited body stores, an increase in energy expenditure, and/or an immaturity and inability to tolerate enteral feedings These issues all affect the preterm infant’s ability to grow sufficiently over time Therefore, parenteral nutrition is generally given immediately after birth to these infants and enteral feedings are introduced in small amounts over time (Pointdexter & Schanler, 2012) Studies have demonstrated that small volumes of feedings over p0260 time, called trophic feedings, that are given early to preterm low-birth-weight infants yield better outcomes in advancement and tolerance of feedings Importantly, using this modality and method of enteral feeding has demonstrated that these neonates may be on total parenteral nutrition for fewer total days (Pointdexter & Schanler, 2012; Slagle & Gross, 1988) The initiation of trophic feedings and titration of increasing enteral feedings decrease parenteral nutrition, usually over a period of several days to weeks Human milk remains the preferred enteral feeding using these strategies The initiation of trophic feedings may begin with 10 mL/kg/day and advance by 10 to 258 ■ II: Special Care Considerations in Neonatal Nursing 20 mL/kg/day until total enteral intake is equal to 150 mL/kg/day (Ehrenkranz, 2007) The total caloric intake of enteral feedings for premature infants p0265 may range between 110 and 135 kcal/kg/day (Agostoni et al., 2010) These caloric requirements are derived from the preterm low-birth-weight infant’s energy expenditure Within the energy expenditure, the infant’s resting metabolic rate is the largest component of the total estimated energy requirement Other energy expenditures that contribute to energy requirements are movement, activity, thermoregulation, and growth Compromising these entities is that the preterm infant has limited energy storage of fat and lean mass The preterm also has energy losses that are due to incomplete absorption of nutrients and immature body organs (Pointdexter & Schanler, 2012) Enteral nutrition and preterm low-birth-weight infant feeding may be increased over time as the neonate tolerates A mean weight gain for the preterm infant is approximately 15 g/kg/day Regaining the neonate’s birth weight by the seventh to fourteenth day of life is one goal that may utilize these approaches (Cloherty, Eichenwald, & Stark, 2012) As with all nutrition, the major components of enteral nutrition are protein, fat, and carbohydrates The preterm low-birth-weight infant is at a disadvantage when trying to feed and absorb these nutrients ti0085 PROTEIN p0270 Gastric acid is required for protein breakdown The preterm infant’s gastric acid levels are lower than those of term infants (Anderson, 2014) Protein requirements for very low-birth-weight and premature infants are g/kg/day A recommended intake of enteral protein by fortified human milk and/or premature formula would need to supply 3.2 to 4.1 g protein/100 kcal Fortified human milk and/or premature formula is derived to yield an increased protein accretion and improved weight gain without causing toxicity to the infant (AAP, 2012; Pointdexter & Schanler, 2012) 7: Nutrition ■ 259 ti0090 FAT p0275 Human milk contains fat, a major energy source Fat comprises nearly 50% of breast milk’s calories, although the fat content varies from mother to mother Fat may adhere to collection containers, feeding tubes, and/or syringes when administering and/or storing human milk Because of this, human milk administration is performed judiciously Times and dates are noted when it is being administered to premature low-birth-weight infants (Pointdexter & Schanler, 2012) Fats are broken down to triglycerides and fatty acids by enzymes located in the infant’s lingual secretions, from the pancreas, and in the intestines (Anderson, 2014) A recommended intake of fat for enteral-fed premature low-birth-weight infants ranges between 4.8 and 6.6 g/kg/day Medium-chain triglycerides are the major source of fat in formula (Agostoni et al., 2010; Pointdexter & Schanler, 2012) Fat makes up 40% to 50% of total caloric intake of either human milk or formula (Anderson, 2014) ti0095 CARBOHYDRATES p0280 Lactose is the primary carbohydrate in human milk Lactase (beta-galactosidase) is an intestinal enzyme that hydrolyzes lactose to glucose and galactose in the small intestine The preterm infant, due to his or her immaturity, has a lower level of lactase yet will tolerate lactose in human milk well (Pointdexter & Schanler, 2012) Glucose polymers are found as the source of carbohydrate in premature formula Glucose polymers have an advantage in that they increase caloric density without a rise in osmolality Recommended carbohydrate intake for premature infants is 11.6 to 13.2 g/kg/day (Agostoni et al., 2010; Pointdexter & Schanler, 2012) ti0100 READINESS FOR ORAL FEEDING p0285 The premature infant’s coordination of sucking, swallowing, and breathing is a highly organized behavior (Medoff-Cooper, Verklan, & Carlson, 1993) This coordination occurs around 32 to 34 weeks g estational age (Delaney & Arvedson, 2008; Jones, 2012) 260 ■ II: Special Care Considerations in Neonatal Nursing The coordination of swallowing and breathing matures around 37 weeks corrected gestational age (Amaizu, Shulman, Schanler, & Lau, 2008; Koenig, Davies, & Thach, 1990; Lau, Smith, & Schanler, 2003) It has been noted that in clinical practice oral feeding initiation may occur as early as 28 to 32 weeks (DeMauro, Patel, M edoff-Cooper, Posencheg, & Abbasi, 2011; Kirk, Alder, & King, 2007) The preterm infant has immature organs that contribute to p0290 enteral feeding issues There is a relaxation of the lower esophageal sphincter, which contributes to the reflux A delay in gastric emptying and a decrease in intestinal motility also are noted Intestinal motility usually starts to improve around 32 weeks gestation (Anderson, 2014) There is an incompetence of the ileocecal valve, which acts as a barrier between the small and large intestine There is also an impaired retro sphincter reflux that can be noted in a delay in stool evacuation (Anderson, 2014) ti0105 CALCIUM AND PHOSPHOROUS p0295 Calcium and phosphorus are essential for all neonates The remature infant requires greater quantities of calcium and phosp phorus than the term infant; these quantities are not available in human milk Calcium and phosphorus are necessary for 99% and 85%, respectively, of bone mass Human milk contains calcium and phosphorus that is ionized easily; thus, it is better absorbed than the calcium and phosphorous that is contained in formula (Pointdexter & Schanler, 2012) Although the calcium and phosphorous in human milk are p0300 better absorbed by neonates, in the preterm infant the amount of calcium and phosphorus in human milk is not adequate enough to attain the intrauterine accretion growth rates This is exhibited in low serum and urine phosphorous concentrations, elevated serum alkaline phosphatases, and elevated urine calcium concentrations (Pointdexter & Schanler, 2012) Human milk supplementation of calcium and phosphorus p0305 improves retention of these minerals in the preterm infant Preterm formulas are fortified with greater amounts of calcium and phosphorous than term infant formulas (Pointdexter & Schanler, 2012) 7: Nutrition ■ 261 ti0110 PARENTERAL NUTRITION p0310 The largest component of the total estimated energy requirement is that needed for the resting metabolic rate When nourished parenterally, the premature infant has less fecal energy loss, generally fewer episodes of cold stress, and somewhat lesser activity so that the actual energy needs for growth are lowered to 80 to 100 kcal/kg/ day for the first week of life (Schanler, 2015) Parenteral nutrition initiated early in this population minimizes p0315 weight loss, improves growth and neurodevelopmental outcome, and appears to reduce the risk of mortality and morbidity There is literature to support better neurodevelopmental outcomes with initiation of higher protein intake (Christmann et al., 2013; Ehrenkranz et al., 2011; Moyses, Johnson, Leaf, & Cornelius, 2013) ti0115 PROTEIN p0320 Recommendations are that 1.5 g/kg/day of protein be started within the first 24 hours after birth and then increased to 3.5 to g/kg/day by 0.5 to g/kg/day increments There are not significant increases in blood urea nitrogen (BUN) and/or acidosis with this higher protein initiation (Burattini et al., 2013; Clark, Chace, & Spitzer, 2007; Klein, 2002; Porcelli & Sisk, 2002; Schanler, 2015; Schanler, Shulman, & Prestridge, 1994; Tan & Cooke, 2008) Essential and nonessential amino acids are necessary to attain a positive nitrogen balance leading to attainment of growth (Malloy, Rassin, & Richardson, 1984) Studies have shown that administering protein of ≥ 4 g/kg/day p0325 was well tolerated and yielded an association of lower rates of bronchopulmonary dysplasia when compared with lower protein (Malloy et al., 1984) Currently, recommendations are to start protein/amino acids administration immediately after birth with an infusion rate of 3.5 g/kg/day There is an improved nitrogen balance and stable serum BUN or glucose concentrations with these higher doses (te Braake, van den Akker, Wattimena, Huijmans, & van Goudoever, 2005; Thureen, Melara, Fennessey, & Hay, 2003) Infants who receive protein on the first day of life have a positive nitrogen 262 ■ II: Special Care Considerations in Neonatal Nursing balance with no side effects from the amino acids (Ibrahim, Jeroudi, Baier, Dhanireddy, & Krouskop, 2004; Poindexter & Ehrenkranz, 2015) As for toxicity, there are no differences between g/kg/day p0330 compared with g/kg/day in serum BUN (Paisley, 2000) Estimated parenteral protein requirements for premature infants who are low birth weight are to 3.5 g/kg/day Estimates for term infants are 2.5 to g/kg/day (Poindexter & Denne, 2012) TrophAmine is a brand of amino acid solution that yields normal p0335 amino acid plasma concentrations (Thureen et al., 2003) TrophAmine and Premasol supply amino acids L-tyrosine and N-acetyl-L-Tyrosine Aminosyn-PF and Primene not supply substanial tyrosine Cysteine is not in most parenteral amino acid solutions The ideal intravenous amino acid is not known for parental nutrition (Poindexter & Ehrenkranz, 2015) ti0120 GLUCOSE p0340 As with enteral nutrition, carbohydrates and fat primarily provide the calories for energy The percentages of nonprotein calories are carbohydrates 40% and lipids 45% (Schanler, 2015) Others have noted the fat to glucose ratio can mimic human milk 60:40 (Poindexter & Ehrenkranz, 2015) Glucose is the source of carbohydrate used in parenteral nutrition Initially, exogenous glucose is often needed until the infant can begin to mobilize glycogen stores and produce glucose Term infants, due to their utilization and glucose production, p0345 need to 5 mg/kg/minute Preterm infants’ demands are greater: to mg/kg/minute Preterm infants may start at a glucose infusion rate of mg/kg/day and increase as high as 10 to 12 mg/kg/minute as long as hyperglycemia does not occur Glucose infusion rates of to mg/kg/minute may be needed The primary source of energy for the neonatal brain is glucose (Poindexter & Ehrenkranz, 2015) Very-low-birth-weight infants who weigh 1,000 g or more will usually tolerate 10% glucose–dextrose solution Infants that weigh less than 1,000 g may require 5% glucose–dextrose solution (Poindexter & Ehrenkranz, 2015) 7: Nutrition ■ 263 ti0125 FAT p0350 Fat emulsions are important to prevent essential fatty acid eficiency and serve as a nonprotein energy source These emuld sions are from soybean oil, olive oil, medium chain triglycerides, and fish oil The fish oil emulsions contain very long chain omega-3 fatty acids, docosahexaenoic acid, and eicosapentaenoic acid (Mayer & Schafer, 2006; Poindexter & Ehrenkranz, 2015) Lipids can be given mg/kg/day Plasma lipid clearance improves when intravenous lipids are given continuously over 24 hours (Poindexter & Ehrenkranz, 2015) ti0135 REFERENCES Agostoni, C., Buonocore, G., Carnielli, V P., De Curtis, M., Darmaun, D., Decsi, T., … ESPGHAN Committee on Nutrition (2010) Enteral nutrient supply for preterm infants: Commentary from the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) committee on nutrition Journal of Pediatric Gastroenterology Nutrition, 50(1), 85–91 Amaizu, N., Shulman, R J., Schanler, R J., & Lau, C (2008) Maturation of oral feeding skills in preterm infants Acta Pediatric, 97(1), 61–67 American Academy of Pediatrics (2005) Breastfeeding and the use of human milk, policy statement Pediatrics, 115(2), 496–506 American Academy of Pediatrics (2012) Breastfeeding and the use of human milk section on breastfeeding Pediatrics, 129(3), e837–e841 American Academy of Pediatrics Committee on Nutrition (1985) Nutritional needs of low-birth-weight infants Pediatrics, 75(5), 976–986 Anderson, D (2014) Nutrition management of the preterm infant In C. 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Micrencephaly 11 2 Macrencephaly 11 4 Disorders of Neuronal Migration 11 8 Neonatal Seizures 11 8 Brain Injury in Preterm Infants 12 5 Germinal Matrix-Intraventricular Hemorrhage 12 6 White Matter... Hemorrhage 15 2 Subdural Hemorrhage 15 4 Perinatal Stroke 15 6 Spinal Cord Injury 15 9 Peripheral Nerve Injuries 16 1 Radial Nerve Injury 16 1 Median and Sciatic Nerve Injuries 16 1 Facial Nerve Palsy 16 2... Kangaroo Mother Care 403 Step-by-step Kmc Procedure 404 Positioning 407 11 The Neonatal Intensive Care Unit Environment 413 Leslie B Altimier Overview 413 Neuroprotective Care 414 Neonatal Integrative