Nutritional sufficiency of the newborn is a topic that continues to engage great debate. Delivery of the fetus is marked by the abrupt transition from the fetal nutritional state. This state is marked by a relatively constant supply of nutrients via the maternoplacental circulation, supplemented to a minor degree by enteral absorption of nutrients derived from swallowed amniotic fluid. The transition to an intermittent and wholly enteral route for neonatal nutritional needs is a critical aspect of successful adaptation at birth.

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Infants who are born prematurely commonly lack regulatory mechanisms to control essential life functions, such as regular breathing, thermal homeostasis, and enteral intake of nutrients. They often require assisted ventilation and supplemental oxygen beginning at birth, and an immature heart and circulation sometimes leads to systemic hypotension, inadequate organ perfusion with resultant oliguria, and metabolic acidosis. Thus, frequent or continuous monitoring of vital signs, namely temperature, blood pressure, heart rate, breathing pattern, and oxygen saturation, is an extremely important aspect of intensive care for very immature infants. Monitoring of these critical variables should begin immediately after birth, with appropriate provision of an adequate heat source to prevent hypothermia in the delivery room and during transport to the intensive care nursery; assisted ventilation with sufficient supplemental oxygen to prevent hypoxia and hypercapnia; and early intravenous access to allow delivery of glucose-containing solutions and emergency drugs if needed.

In the intensive care nursery, a more thorough assessment of the infant’s condition should include accurate baseline measurements of body weight, length, and head circumference to identify possible discordance between gestational age and prior intrauterine growth. For management of extremely small, immature, and sick newborns, it is often useful to care for the infant on a platform balance beneath the bedding to allow frequent weight determination with minimal disturbance of the infant. The infant should remain in a warm environment, with continuous monitoring of heart and respiratory rates, oxygen saturation (SaO₂; pulse oximetry), and temperature. If extra oxygen is needed, with or without mechanical ventilation, partial pressures of oxygen (PaO₂) and carbon dioxide (PaCO₂) should be measured at frequent intervals or monitored continuously with transcutaneous electrodes. The target for PaO₂ should be 50 to 80 mm Hg (SaO₂ 90–95%), and the target for PaCO₂ should be 40 to 50 mm Hg, although higher values for PaCO₂ may be tolerated to reduce the risk of lung injury if the infant is being managed on mechanical ventilation.

In all seriously ill preterm infants, and in those who have evidence of poor peripheral Continue reading »

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